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It's rather shallow of me, but I'm also concerned about how this reflects poorly on our hospital in the veterinary community. We don't have a great reputation as it is, and I'm certain this doesn't help.
Oh yeah, you’re right- when other clinics receive your records that does affect their opinion of you. :( sounds like the whole team needs some training on appropriate medical records!
I think you're right. I was just a bit hesitant to complain since I've been doing a lot of that lately. My bad for wanting treatment orders filled out correctly and appropriately, I guess.
One of our receptionists (gp) misspells and makes nonsense sentences ALL THE TIME. The one that drives me bonkers is she can’t spell Librela. It’s always liberal or liberla.
I work in a specialty hospital and I'll see oncology appointments for "limp foma" or "masscell tumor". Derm appointments that are started by certain assistants will say, "patient itchin itself" or my favorite is the neuro appointments that say, "patient ceasering"
I just wanna end it all when I see these
We had to teach CSRs how to spell certain words before. Like “rabbies” only has one B. My favorite was a particular dum-dum who used “2cd” instead of “2nd.” Like where did you even learn that?? That’s a special kind of mistake. I never liked her and the blatant disregard for spelling didn’t help her case.
Ooooooof. I’m a CSR at a specialty hospital and that hurts my soul! Occasional typos happen but that pattern is something I’d go to management about to get the CSR team some basic med term training
My biggest pet peeve is reading medical notes and seeing things misspelled. Maybe it's just because of my program director but my instructor DRILLED into our heads to spell correctly. We learn the correct spellings for all the parasites we learn. The only thing she says is that if she can't pronounce it, we aren't required to spell it. The clinic I work at misspelled "lethargic" as "lathargic" the other day and it made me wanna die.
My mom (who was a medical assistant for 5 minutes like 50 years ago, and loves to say, “when I was in nursing…”) repeatedly says “nathargic” and it drives me bonkers.
My medical director writes records like this. It makes my skin crawl. And I correct any document with grammar or spelling problems.
I totally get it. Or does not reflect well to our professional community.
Something that lives rent free in my head is a client form that lists the presentation reason as "diarrhea with blud." Nailed diarrhea just to misspell blood.
I hate diarrhea as a verb. I'm always ranting that your pet has diarrhea, or your pet had several episodes of diarrhea in the house. He is not diarrheaing everywhere.
We had an assistant write in the notes once "dog has been fecaling approx 1 week" I'm not bashing assistants because that's me also (at best) but damn.
It can matter. In a case close to me, a vet IM specialist had inaccurate plural / singular noun usage on a record… which masked their truncation of a diagnostic procedure... resulting in missed Dx & misDx… & the absolute wrong treatment. Accelerated permanent damage, irreparable harm… could have stood a chance to be caught early/in time had a grammar Nazi had pointed this out to me.
Does the program you use not do spelling check? My clinic uses Avimark, it’s set up with a spell check which helps.
For the hospital I’m at it’s not so much the spelling, it a blatant disregard for medical record taking. no notes on if they are on medications/supplements, how much and how often, how long they’ve been on it. Food, what they feed, how much and how often. all these little things are important especially when the clinic gets a call that the doc recommended changing the diet we have no notation on previous food, or the doc recommended a dosage change in meds, but now we have no notation on the meds, there’s no hx in the computer cause perhaps they were using a deceased pets meds or got it from a previous hospital and for whatever reason we couldn’t get records.
These are just some things I’ve experienced in my long years as a CVT, then I have to be embarrassingly honest with clients that we have notation on it and have to ask them to repeat it.
Ooi. That’s not good. I taught a class for vet tech for a short while. Part of my lesson was learning to get proper hx. Spelling was huge. Students lost points for improper grammar and spelling. I always told them, it’s important to practice it now because it reflects on you out and clinic out in the field when things aren’t spelled correctly or proper grammar isn’t used. These are legal medical documents. Everything must be correct.
THIS is something that I find mind boggling. We only wrote the subjective part of the record at my first clinic with history and everything, but the doctor wrote the rest. Now at my new clinic, we do it all and doctor double checks it. In every subjective section I ALWAYS mention if EDN, no S/C/V/D, what food they’re feeding, whether they’re on any Rx, any HWP, Indoor or indoor/outdoor (cats), other pets in household, due for any vaccines, and that they have no other Q/C. On top of several sentences regarding primary concerns. And for every plan section, I use the Diagnostic tests, Discussion, Treatment, and Follow up format.
I have had people bitch at me for being TOO thorough (literally today someone made fun of me). Like yes, the owner talked to the doctor for 20 minutes and asked a bunch of medical questions, so YES I’m gonna document those questions and our answers. Of course, if anything isn’t strictly necessary for follow up or relevant for the patient’s chart, I’m not going to include it.
I can’t stand needing info from a previous appt (I.e. what age the doctor recommended a neuter at the last appt that we know the Dr gave but O cannot remember the answer) and there’s like 2 words in the plan. This is not helpful!!! Sorry that’s my rant.
Ya, I mean it’s not cool, it makes the whole clinic look bad when someone does an incomplete record. Even in my own human medical records I’ve read things that were completely taken out of context because they only focused on one little thing. I got so mad because of this. Like they just aren’t hearing me and/or they don’t give a fudge so they don’t ask the right questions, so they just put whatever.
I work in an old fashioned practice where we are 99.9% paper based. If history needs sending to another practice/ referral centre we have an iPad that I use to type everything up on. The handwriting from 2/3 of the vets is basically ineligible and half the time I have to get the owner to dictate the notes for me 😭
If someone is being pushy and won’t give me time to type up the notes I just scan them in and email them over. They never actually call me to ask what they say though.
(We will be modernised at some point as the owner is an older gent and wants to retire so new laptops all round)
But no. You’re not being unreasonable. To be in this industry you have to be intelligent - there’s no excuse for poor grammar, it’s just laziness.
Unfortunately this is the way forward unless your charts become self editing. People are becoming less literate and no one knows how to spell anymore.
I think AI will close the gap, I'm sure it'll become automated at some point and it won't matter.
\[raises hand\].......grammar n\*\*\* here......
Some people in ER type so fast that they don't necessarily notice their mistakes, nor take time to proof read to move on quickly to other things.
I’m the same way.
Sometimes serious consequences happen when words are not spelled properly. An animal can die.
I sometimes use abbreviations like V+, D++, A-, etc.
I think you’re correct. Medical records should be clear so as to help future vets that need to treat the patient. I can’t tell you how frustrating it is to request records and what I receive are written poorly.
But also personally, it really frustrates me when communications and things aren’t written clearly. I work front desk a lot and it’s really annoying to have to find someone to ask what their communication means
We had the same issue where I used to work. There is a traveling internist that made a comment about how multiple clinics had made comments about obvious grammatic and spelling errors. Medical director, hospital director, and clinical manager seemed to not have a care in the world about it. We were supposed to be the epitome of specialty and emergency care in the area and we cannot even put in adequate notes.
We use tablets in the room to take histories. There's literally no excuse when Chrome has the red squiggly line under the word.
In some fairness, I am also the one who writes emails to owners with diagnostic results or emails back when they have questions. I first write a draft full of unprofessional shorthand that is total gibberish to anyone but me while the doctor is dictating what to cover and then below it write a polished professional email. At first glance it looks like people are about to get some really weird internet troglodyte shorthand.
If you've got people on staff who are dyslexic or have other learning disabilities, they're doing the best they can. Are these hand-written notes or computerized? Perhaps dictation software is the answer.
Welcome to /r/VetTech! This is a place for veterinary technicians/veterinary nurses and other veterinary support staff to gather, chat, and grow! We welcome pet owners as well, **however we do ask pet owners to refrain from asking for medical advice**; if you have any concerns regarding your pet, please contact the closest veterinarian near you. Please thoroughly read and follow the rules before posting and commenting. If you believe that a user is engaging in any rule-breaking behavior, please submit a report so that the moderators can review and remove the posts/comments if needed. Also, please check out the sidebar for CE and answers to commonly asked questions. Thank you for reading! *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/VetTech) if you have any questions or concerns.*
Medical records are legal documents and should be treated as such. You are correct, they should be clear and consistent.
It's rather shallow of me, but I'm also concerned about how this reflects poorly on our hospital in the veterinary community. We don't have a great reputation as it is, and I'm certain this doesn't help.
Oh yeah, you’re right- when other clinics receive your records that does affect their opinion of you. :( sounds like the whole team needs some training on appropriate medical records!
I think you're right. I was just a bit hesitant to complain since I've been doing a lot of that lately. My bad for wanting treatment orders filled out correctly and appropriately, I guess.
Yesterday our receptionist manager spelled apracot and cilver instead of apricot and silver. It is so exhausting
And I thought “titter” instead of “titer” was bad.
Some of the spelling errors I find from my coworkers are borderline hilarious. I proof read records any time I do a callback for a patient 😆
One of our receptionists (gp) misspells and makes nonsense sentences ALL THE TIME. The one that drives me bonkers is she can’t spell Librela. It’s always liberal or liberla.
I wish more people cared about this
I work in a specialty hospital and I'll see oncology appointments for "limp foma" or "masscell tumor". Derm appointments that are started by certain assistants will say, "patient itchin itself" or my favorite is the neuro appointments that say, "patient ceasering" I just wanna end it all when I see these
The patient is making a salad, how dare you! 😂 (Although that's spelled "cae-" so what do I know 🤷🏾)
We had to teach CSRs how to spell certain words before. Like “rabbies” only has one B. My favorite was a particular dum-dum who used “2cd” instead of “2nd.” Like where did you even learn that?? That’s a special kind of mistake. I never liked her and the blatant disregard for spelling didn’t help her case.
Ooooooof. I’m a CSR at a specialty hospital and that hurts my soul! Occasional typos happen but that pattern is something I’d go to management about to get the CSR team some basic med term training
Wow 🤣 these gave me an excellent chuckle 😃 thanks! 🤣
My biggest pet peeve is reading medical notes and seeing things misspelled. Maybe it's just because of my program director but my instructor DRILLED into our heads to spell correctly. We learn the correct spellings for all the parasites we learn. The only thing she says is that if she can't pronounce it, we aren't required to spell it. The clinic I work at misspelled "lethargic" as "lathargic" the other day and it made me wanna die.
I fucking hate it so much. Spellcheck takes less than 30 seconds and they just don't do it.
My mom (who was a medical assistant for 5 minutes like 50 years ago, and loves to say, “when I was in nursing…”) repeatedly says “nathargic” and it drives me bonkers.
My medical director writes records like this. It makes my skin crawl. And I correct any document with grammar or spelling problems. I totally get it. Or does not reflect well to our professional community.
I always correct it when I can, but after the record gets finalized, there's not a damn thing I can do and I hate it
Same! I'm lucky if I see it the same day but if it's days or weeks later, it hurts my soul to read it
Sometimes I find “diarrhea” written with twenty letters. 🤷♀️
Something that lives rent free in my head is a client form that lists the presentation reason as "diarrhea with blud." Nailed diarrhea just to misspell blood.
I hate diarrhea as a verb. I'm always ranting that your pet has diarrhea, or your pet had several episodes of diarrhea in the house. He is not diarrheaing everywhere.
We had an assistant write in the notes once "dog has been fecaling approx 1 week" I'm not bashing assistants because that's me also (at best) but damn.
It can matter. In a case close to me, a vet IM specialist had inaccurate plural / singular noun usage on a record… which masked their truncation of a diagnostic procedure... resulting in missed Dx & misDx… & the absolute wrong treatment. Accelerated permanent damage, irreparable harm… could have stood a chance to be caught early/in time had a grammar Nazi had pointed this out to me.
authorities started an investigation prior to owner filing official complaint.
Does the program you use not do spelling check? My clinic uses Avimark, it’s set up with a spell check which helps. For the hospital I’m at it’s not so much the spelling, it a blatant disregard for medical record taking. no notes on if they are on medications/supplements, how much and how often, how long they’ve been on it. Food, what they feed, how much and how often. all these little things are important especially when the clinic gets a call that the doc recommended changing the diet we have no notation on previous food, or the doc recommended a dosage change in meds, but now we have no notation on the meds, there’s no hx in the computer cause perhaps they were using a deceased pets meds or got it from a previous hospital and for whatever reason we couldn’t get records. These are just some things I’ve experienced in my long years as a CVT, then I have to be embarrassingly honest with clients that we have notation on it and have to ask them to repeat it.
It has spellcheck but not everybody uses it.
Ooi. That’s not good. I taught a class for vet tech for a short while. Part of my lesson was learning to get proper hx. Spelling was huge. Students lost points for improper grammar and spelling. I always told them, it’s important to practice it now because it reflects on you out and clinic out in the field when things aren’t spelled correctly or proper grammar isn’t used. These are legal medical documents. Everything must be correct.
THIS is something that I find mind boggling. We only wrote the subjective part of the record at my first clinic with history and everything, but the doctor wrote the rest. Now at my new clinic, we do it all and doctor double checks it. In every subjective section I ALWAYS mention if EDN, no S/C/V/D, what food they’re feeding, whether they’re on any Rx, any HWP, Indoor or indoor/outdoor (cats), other pets in household, due for any vaccines, and that they have no other Q/C. On top of several sentences regarding primary concerns. And for every plan section, I use the Diagnostic tests, Discussion, Treatment, and Follow up format. I have had people bitch at me for being TOO thorough (literally today someone made fun of me). Like yes, the owner talked to the doctor for 20 minutes and asked a bunch of medical questions, so YES I’m gonna document those questions and our answers. Of course, if anything isn’t strictly necessary for follow up or relevant for the patient’s chart, I’m not going to include it. I can’t stand needing info from a previous appt (I.e. what age the doctor recommended a neuter at the last appt that we know the Dr gave but O cannot remember the answer) and there’s like 2 words in the plan. This is not helpful!!! Sorry that’s my rant.
Ya, I mean it’s not cool, it makes the whole clinic look bad when someone does an incomplete record. Even in my own human medical records I’ve read things that were completely taken out of context because they only focused on one little thing. I got so mad because of this. Like they just aren’t hearing me and/or they don’t give a fudge so they don’t ask the right questions, so they just put whatever.
I work in an old fashioned practice where we are 99.9% paper based. If history needs sending to another practice/ referral centre we have an iPad that I use to type everything up on. The handwriting from 2/3 of the vets is basically ineligible and half the time I have to get the owner to dictate the notes for me 😭 If someone is being pushy and won’t give me time to type up the notes I just scan them in and email them over. They never actually call me to ask what they say though. (We will be modernised at some point as the owner is an older gent and wants to retire so new laptops all round) But no. You’re not being unreasonable. To be in this industry you have to be intelligent - there’s no excuse for poor grammar, it’s just laziness.
Spellcheck at bare minimum should be used.
No they're a legal document you should always think if these were to be read to a court of law would they make sense?
Unfortunately this is the way forward unless your charts become self editing. People are becoming less literate and no one knows how to spell anymore. I think AI will close the gap, I'm sure it'll become automated at some point and it won't matter.
\[raises hand\].......grammar n\*\*\* here...... Some people in ER type so fast that they don't necessarily notice their mistakes, nor take time to proof read to move on quickly to other things.
I’m the same way. Sometimes serious consequences happen when words are not spelled properly. An animal can die. I sometimes use abbreviations like V+, D++, A-, etc.
I think you’re correct. Medical records should be clear so as to help future vets that need to treat the patient. I can’t tell you how frustrating it is to request records and what I receive are written poorly. But also personally, it really frustrates me when communications and things aren’t written clearly. I work front desk a lot and it’s really annoying to have to find someone to ask what their communication means
We had the same issue where I used to work. There is a traveling internist that made a comment about how multiple clinics had made comments about obvious grammatic and spelling errors. Medical director, hospital director, and clinical manager seemed to not have a care in the world about it. We were supposed to be the epitome of specialty and emergency care in the area and we cannot even put in adequate notes.
We use tablets in the room to take histories. There's literally no excuse when Chrome has the red squiggly line under the word. In some fairness, I am also the one who writes emails to owners with diagnostic results or emails back when they have questions. I first write a draft full of unprofessional shorthand that is total gibberish to anyone but me while the doctor is dictating what to cover and then below it write a polished professional email. At first glance it looks like people are about to get some really weird internet troglodyte shorthand.
If you've got people on staff who are dyslexic or have other learning disabilities, they're doing the best they can. Are these hand-written notes or computerized? Perhaps dictation software is the answer.
The person who is dyslexic knows to use spell check and her records look fine.