Choosing the Right Documentation Strategy for Your Veterinary Practice
Comprehensive, accurate documentation is essential for legal compliance, patient safety, and ensuring that critical information is readily accessible when it’s needed most. However, maintaining detailed records can quickly consume valuable time, limiting direct interaction with patients and clients.
How a practice approaches documentation can either drive operational efficiency or create added strain on the team. In an industry where time is precious, finding smarter ways to handle documentation is key to balancing quality care with the demands of a busy practice.
This raises the question: What’s the best documentation approach for a modern veterinary practice?
With technology now playing a pivotal role in how veterinarians manage documentation, it’s important to consider all available options, from AI scribes to traditional methods like doing it yourself.
Option 1: The vet doing it themselves
Many veterinarians prefer to handle their own documentation, writing or typing notes themselves during or after appointments. This approach can feel like a simple way to keep full control over patient details. However, managing documentation alone can quickly become overwhelming, especially for vets with packed schedules.
In busy practices, the demands of seeing multiple patients throughout the day often leave vets with little time to complete their documentation during office hours. As a result, many find themselves catching up on paperwork in the evening or late at night. This extends the workday, cutting into personal and family time, and increases the risk of forgetting key details. By the time a vet sits down to complete notes after hours, important specifics about patient interactions or treatments may be lost or misremembered.
The burden of self-documentation can diminish a vet’s ability to be fully present with patients during the day. Over time, the added strain of trying to keep up with both care and notes can lead to stress and less satisfaction in their work.
Option 2: Using support staff for documentation
Some veterinary practices rely on vet technicians or assistants to handle documentation during appointments. This approach allows the vet to focus fully on the patient while the staff member records the necessary details.
When executed well, this approach can free up significant time for vets. With documentation handled by trained staff, vets can provide more hands-on care, ensuring that patient needs are met without the distraction of taking notes. Plus, support staff are typically already familiar with the clinic’s workflows and procedures, making it easier for them to capture relevant information.
However, relying on staff for documentation comes with its own set of challenges. Increasing the documentation burden on support staff can overload them, pulling them away from other essential tasks. This approach can also lead to delays if the staff member responsible for documentation is occupied with other duties. And like any manual process, human error remains a concern, as staff may miss key details or enter information inaccurately.
Option 3: AI Scribes
AI scribes are transforming how veterinarians handle documentation. AI scribes can listen to conversations during appointments, identify key details, and automatically organize the information into structured medical records.
The best AI scribes integrate with patient information management systems (PIMS), which means they can directly update patient records without requiring any additional manual entry. This connection streamlines the entire documentation process, reducing the chance of errors or missed details while ensuring that records are complete and accurate. Clinics save time and avoid the hassle of transferring information from one system to another, enabling a smoother workflow and minimizing the administrative load on staff.
The technology can be tailored to meet the specific needs of each practice, whether it’s capturing detailed surgical notes or quick summaries of routine exams. This flexibility allows the system to use preferred terminology, include or exclude certain details, and adjust formatting to suit the clinic’s workflow. For busy practices with high standards for documentation accuracy, this level of customization provides an ideal solution, balancing precision with the need for a more efficient workflow.
Option 4: Voice-to-text software
Voice-to-text software is a more basic option, and while it lacks the intelligence of AI scribes, it can still help streamline documentation to some extent. These systems convert spoken words into text, functioning much like the voice dictation feature on smartphones.
Voice-to-text software lacks the ability to integrate with practice management systems, so vets are still left with the task of manually entering the transcribed text into the appropriate fields, which reduces the overall efficiency of the process.
Option 5: Outsourcing to a human scribe
A human scribe is a professional, either on-site or remote, who assists veterinarians by taking detailed notes during patient appointments or surgeries. This individual listens to the conversation between the vet and the client (or reviews a recorded version of the appointment) and transcribes the relevant information into the patient’s medical record. Scribes have long been used in human medicine, and the practice is increasingly common in veterinary clinics.
Outsourced scribes typically operate remotely, which means they rely on clear audio recordings or live calls during appointments. This distance can occasionally lead to miscommunications or a lack of contextual understanding that someone physically present might have.
Finding the right fit for your practice
Choosing the right documentation approach depends largely on the size of your practice, the complexity of your cases, and the resources you have available. For smaller practices with lighter documentation needs, options like voice-to-text or even self-documentation may be enough. However, larger clinics with high volumes of records often find that AI scribes offer essential integration and automation, reducing the documentation burden on vets and staff.
Ultimately, the goal is to strike a balance between accuracy, efficiency, and ease of use.
Practices that invest in the right tools will improve their workflow and enhance the quality of care they provide to their patients. As technology continues to shape veterinary care, the role of AI in documentation will likely grow. By understanding what each option brings to the table, clinics can make informed decisions that support both their operational needs and their long-term growth.
Transform your practice with HappyDoc
HappyDoc helps you transform your entire approach to patient care. Your clinic's staff will have a personalized AI scribe that listens, takes notes, integrates with your software, and files the data away in the appropriate spot. HappyDoc works alongside you so you can be free to focus on what matters—your patients.
Schedule a demo to find out how your clinic can operate at its full potential, providing the highest level of care to every patient, every time.
