Vet's Record Keeping - Is it Important?

In the last 15 years I have been to two different vet clinics for regular checkups and things like that. The first clinic had several doctors who took pretty good notes during exams, and everything was kept in paper records - no electronics. I could almost always obtain a copy by the time I was ready to go home. They used the SOAP note format. If you're not familiar with that then have a look here - http://www.physiciansoapnotes.com/ and here - http://www.unm.edu/~clinic/Procedures/Forms/soap notes.pdf

The second clinic (started by a doctor from the first clinic), however, takes lousy notes. They don't keep paper records. Some vitals and other brief things are jotted down on a piece of paper on a clipboard, but it's never anywhere as detailed as the notes they took while working at the first clinic. This information is at some point entered into the computer by hand - no scanning. I suspect they go back later in the day, if at all, and fill in the information. I have requested copies, only to see that much of what is there is incorrect. This varies from a temperature, to blood pressure, to them stating I refused an x-ray when the subject of an x-ray never even came up during that particular exam! I often times can't even get a copy of the notes before I leave because the doctor hasn't finished them yet (did they even start them?). There were times it took several days to get a copy if I ever got one at all. At one point, I gave up asking because I was getting nowhere.

I feel extremely disappointed here. To me, it seems like taking good notes and having good records would be important to an animal's health, especially if they have a chronic condition or something that can't be diagnosed. The fact that some notes are incorrect is particularly bothersome. The fact that some are downright lies (the part about x-rays) annoys the heck out of me.

Am I wrong in being upset about this?

I'd like to ask the veterinarian/owner if she would consider (at least for my pets) reverting back to taking more detailed notes like she did at the other clinic. I don't see why she can't just take the same kind of notes. It doesn't make sense to me. She could just scan the paper into the computer or enter the info manually at the end of the day. She could give me a copy of the handwritten notes before I leave. Even my own doctor types the notes into the computer during the exam, why can't the vet? To be honest, I haven't seen the other veterinarians at this clinic (they haven't found anyone permanent yet) so I can't comment on what their notes are like. For all I know, maybe that's why they don't stick around. I vaguely remember the veterinarian/owner stating once that she lost my cat's x-rays "in the cloud." I don't know if she ever found them but I find that very upsetting.

How do you all feel about this? What is your stance on good, detailed, accurate note-taking during exams? Maybe I'm being too uptight.

I think it's very important.  I took in some cats after a friend died suddenly.  I knew that three of the cats had quite a few health problems but didn't know the details.  Fortunately their previous vet took extensive notes so I was able to find out relatively easily how to take care of them, even down to what kind of food they were used to.  It would have been very difficult to start caring for those sick kitties properly without good vet records to start from.

I have looked at the list of vets in Ohio that have been disciplined.  The discipline often includes a continuing education requirement and I assume the class ordered has to do with the violation.  Quite often I see a  requirement for a class on record keeping.  Business practices are on the list of things that the vet licensing board has no jurisdiction over so I assume that the record keeping has to do with medical records.

I agree that detailed notes are very important, and even a must for me personally. I actually prefer electronic notes (they are usually more detailed and easier for all to read.) Poor record keeping would likely be a deal breaker for me with any clinic.

Since you have used this particular vet for sometime, I think it would be ok to inquire about why she has chosen to keep records the way she does. Asking for more detailed notes for your kitties is also ok.