Documentation is critical for any business but especially for the veterinary practice. You maintain charts in a prescribed manner following through to leave a paper trail for consultations, exams, tests, treatments, follow-ups and general notes for each patient.
But do you also provide a paper trail for information pertaining to your employees?
OSHA says you definitely should.
Here is what OSHA wants to see in terms of records for employees:
1) Training Documents:
We all know by now that OSHA wants to see specific training on prescribed areas of OSHA that includes not only the definition of what OSHA is, but also who it protects, your rights and responsibilities, as well as training addressing specific potential hazard areas. In addition OSHA wants to see training on clinic procedures and the employee’s specific duties
2) Employee Injuries:
OSHA also wants you to document employee injuries, even if it seems mild and does not require anything beyond first aid, if even that. The reason is that we need to have a paper trail should that simple incident result in a more significant problem. For example, a simply cat scratch may develop later into a raging infection. You document the incident for in-house use. This then provides a record - a paper trail - should you need one later.
3) Workplace Violence Incidents:
This may be an area your paperwork is lacking. We all document the incidents between employees so that we can properly discuss the incident with the involved employees and have the paper trail for disciplinary actions that may include dismissal. But do you also record incidents that deal with clients or other members of the public?
You should! Law enforcement officials are especially adamant about creating a paper trail. When we have a case where, for example, a client stalks an employee, (see Workplace Violence http://www.impromed.com/newsletter/article.aspx?e=&a=259) the first question the investigating officer asks is did you document the incidents leading up to this?
Most of the time the answer is no. It needs to be yes every time.
So how do we document and what specifically are we documenting? Also, how do we file the information and to whom are we reporting this info?
1) How to Document:
Use a specific form each time to ensure you keep a record of all pertinent information for the incident. It may be a good idea to prepare a form beforehand to use for incidents - you can click on this link to go to my web site at http://www.kendricktechservices.com/FreeStuff.html.
2) What to Document:
The form should include the following:
a) Names of people involved
b) Their positions, for example are they employees, clients, related to or accompanying the employees or clients, or members of the general public
c) Date and time of incident
d) What occurred
e) Witnesses to the incident (who was present) and be sure to Include written witness statements
f) Follow-up: were police called, reprimands given, warnings
3) Where to file:
File it in whatever manner feels comfortable to you and your filing system ensuring you can locate it easily if needed later. Some examples are to make a file folder called Incidents and put the original form in that file, with copies going into files of those individuals involved: primary people involved witnesses etc. If the incident involved a client be sure to put a copy in the client record folder, also
If you have a safety consultant, definitely report the incident to the consultant so he or she has a record of the incident, how it was addressed and so he or she can apply the information as needed for development of further training and safety measures.
You may also need to file an incident report with the police. This is immeasurable in order to protect you in terms of liability as well as create a paper trail in case of escalation of the situation. Remember there is never anything too menial to report to your local police or sheriff’s office. They would much rather have you be proactive in this way than to come upon a violent situation with a bad ending where everyone “just knew something like this was going to happen,” and they were never informed that there was a potential problem.
In personal communication with police officers they have repeatedly stressed to me that they want to be pro-active, helping discuss situations before they get out of control. They view their jobs as protective and educational, not simply cleaning up the mess after things have ended in a violent conclusion.
Again, be sure to use your client base for resources in the community. Perhaps you have a police officer or sheriff’s deputy as a client. Or you provide the veterinary care for the police dogs. Ask these officers if they would like to come in and discuss workplace violence issues with your team and help you find ways to keep all safer.
It can be a tense world and unfortunately that tension can bleed over into our clinics. Do the best you can to be proactive to prevent workplace violence and be sure to remember documentation is critical to protect not only your employees but also you and your business.
Chery F. Kendrick, DVM, MPVM, MLT, CFS is a writer, educator, speaker and consultant. She is the nation’s leading veterinary regulatory control expert, and spends time in Washington D.C., advocating for the veterinary profession at the various regulatory agencies. Her manuals and training programs are used by clinics and animal care facilities nationwide. She speaks nationwide at association meetings and workshops. Please feel free to contact her at chery@KendrickTechServices.com with your questions or visit her web site at www.KendrickTechServices.com