General requirements
Veterinarians are expected to:
know when to refer cases
know when a second opinion may be appropriate
understand and respect clients' rights to seek a referral or second opinion
be familiar with their obligations under the Privacy Act in these circumstances.
When asked to provide clinical records about an ongoing clinical case to another practice, veterinarians must be satisfied that the client has consented to the information being released. Clients can provide consent directly to the veterinarian who holds the clinical records, or can transfer their right to access the information to their new veterinarian. In the second situation the client's new veterinarian makes the request for the clinical records. If in any doubt the veterinarian asked to release the clinical records is entitled to ask for evidence that client consent has been given.
Consent may be given verbally or in writing. If verbal consent is given this should be noted in the clinical records. Any conditions on the release of the information should also be recorded.
The provision of relevant clinical records:
ensures that all veterinarians providing services to the animal(s) have relevant historical clinical information to help ensure optimal clinical outcomes and patient safety
keeps both veterinarians informed of each other's involvement and helps ensure the client receives consistent professional advice. When this doesn't happen there is a greater likelihood of client dissatisfaction and an increased potential for complaints.
Second opinions
A second opinion involves seeking an evaluation by another veterinarian to confirm a diagnosis and treatment plan, or potentially to offer an alternative diagnosis and/or treatment options.
Veterinarians may recommend a second opinion for a variety of reasons, for example in complex cases or where there are concerns the client may not accept the treatment recommendations.
Clients may also decide to seek a second opinion without discussing this with their usual veterinarian. They may be apprehensive about their veterinarian's proposed course of treatment or costs; unhappy with the care provided; or hesitant to request a second opinion in case they offend.
Where veterinarians propose euthanasia on welfare grounds and the animal's owner does not accept the recommendation, owners must, on request, be given the opportunity to obtain a second opinion within a reasonable time frame. This is a legal requirement under Section 138 Animal Welfare Act 1999. In situations where veterinarians are not confident that the owner will follow through on obtaining a second opinion and the animal may suffer, they may put a time limit on gaining the second opinion after which an animal welfare/SPCA inspector will be notified.
When veterinarians recommend a second opinion they should help clients by recommending one or more veterinarians with the appropriate expertise. The first veterinarian must provide the relevant clinical records and should contact the second opinion veterinarian to notify them of the possible client visit.
Second opinion veterinarians must be careful not to discredit the first veterinarian. When second veterinarians know the client has sought a second opinion to clarify or confirm the first veterinarian's diagnosis and/or treatment options, they should, after providing the second opinion and providing they are in agreement with the first veterinarian, encourage the client to return to the first veterinarian.
If, after obtaining a second opinion, clients choose not to return to the original clinic, or to have the treatment/investigations carried out at the second opinion clinic, first veterinarians must respect this
Referral
Referral involves handing over a case to a veterinarian with particular skills in the appropriate discipline. Clients should be told whether the referral veterinarian is a registered specialist; if not, the client should be given details of their particular skills, training and experience.
The purpose of referral is to obtain a diagnosis and carry out treatment with the expectation that the client will return to the referring veterinarian.
If veterinarians offer referral but the client declines, this should be noted in the clinical record. Consideration should also be given to including this information in consent forms.
Veterinarians should be familiar with the referral options available to their clients and consider offering referral early in appropriate cases. Referring veterinarians must provide relevant clinical records to referral veterinarians. If documentation can't be provided before the appointment, referring veterinarians should phone referral veterinarians to discuss the case.
Referral veterinarians must provide referring veterinarians with detailed reports on diagnoses, treatments and prognoses for referred animals. If clients are provided with a written report, the original veterinarian should also receive a copy.
Client initiated transfers and consents
When clients transfer the care of their animal to another veterinarian their consent must be obtained before contacting the first veterinarian to request the clinical records (unless information is required to assist emergency treatment).
In seeking client consent it is important that veterinarians explain the benefits of having access to relevant clinical information about the animal(s).
When clients don't consent to the second veterinarian communicating with or obtaining clinical records from the first veterinarian, the second veterinarian must consider whether they are able to provide services. The previous clinical records may contain important clinical information. Without this, outcomes and patient safety could be compromised.
Veterinarians must exercise their professional judgement in deciding whether to proceed, balancing the Code's expectations against the best interests of the patient. The welfare and safety of the patient should be of primary importance in making this decision.
When a client refuses permission to communicate with the previous veterinarian, and the second veterinarian elects to treat the patient, it is strongly recommended that this refusal is documented, preferably with the client's signature confirming the appropriate process and discussion has occurred.
With the client's consent, second veterinarians must try to notify the first veterinarian before providing treatment or advice. This demonstrates professional courtesy, and helps ensure optimal clinical outcomes and patient safety. If this isn't possible, the first veterinarian must be told as soon as possible afterwards. Open and honest communication between veterinarians leads to better communication between the second veterinarian and the client and reduces misunderstandings and the likelihood of complaints.
Accessing, providing and documenting client information for second opinions referrals and transfers
Clinical records belong to the owners of the veterinary practice. However the information in them is the client's. Unless there are legal grounds for withholding this information, veterinarians must release copies, or summaries, of relevant information from their clinical records to clients on request (or to the client's new veterinarian with the client's consent).
When veterinarians obtain client consent to access previous clinical records, they are acting as the client's agent and are entitled to seek relevant clinical records from the first veterinarian. This veterinarian does not need to contact the client to confirm their permission to release the records, but if in any doubt can ask the second veterinarian for evidence that consent has been given.
Clients have the right to limit how much information second veterinarians are authorised to obtain from first veterinarians. For example clients may authorise second veterinarians to obtain clinical information relating to the case but not allow the transfer of financial information. It is recommended that veterinarians clarify with clients what information they are authorised to access.
Second veterinarians need to document that the client has given consent to them to obtain the clinical records of their animal(s) (including any limits set by the client on the extent of the information to be provided). Ideally a written consent form tailored to the circumstances should be signed by the client and kept on file. If a signed form or emailed consent is not possible, a note must be made in the patient's clinical record at the time consent was obtained.
Clinical records should be sent in the format requested. If there are initial time pressures, records can be provided in the most appropriate way (depending on the urgency of the situation). This could be verbally providing the details, or faxing or emailing them. If it's not urgent, posting the information may be sufficient. Veterinarians are expected to use their professional judgement to decide what is acceptable and appropriate in the particular circumstances. The patient's welfare must not be compromised by the decision on how to provide the clinical records.
Clinical records should contain all relevant information including case notes, x-rays, lab results, drugs used and treatment details. Point 4(a) of the Veterinary services section of the Code requires a patient's clinical record to contain sufficient detail for another veterinarian to take over the management of the case at any time.
It is not acceptable to delay providing the information because the first veterinarian is not available. Veterinarians/practice owners have professional and legal responsibilities to release relevant clinical information in a reasonable timeframe. To ensure there are no delays, clinic staff, acting on the authority of the first veterinarian, must be delegated the authority to release the required clinical information to the second practice. Similarly, staff can, on the instructions of the second veterinarian, notify the first clinic that the animal is about to be seen or has been seen, and request previous relevant clinical records.
Individuals have the right to access the personal information held by veterinarians about themselves (including information about their animals).
When veterinarians respond to a client's request to access the clinical records of their animal(s), they must ensure they only provide the requested information and do not inadvertently pass on information that relates to others.
Veterinarians cannot charge for collecting, collating, sorting or redacting (obscuring or deleting) personal information.
Veterinarians may charge clients for:
the reasonable time spent copying the clinical records where this exceeds 30 minutes
copying costs where the number of pages exceeds 20.
Refer to the Ministry of Justice's Charging Guidelines for Official Information Act 1982 Requests. These guidelines are relatively generous and the Privacy Commissioner has stated that a reasonable charge in some circumstances will be considerably less that these guidelines permit.
Professional obligations and courtesies
Second veterinarians are not obliged to provide the original veterinarian with information on their planned treatment of the case or details of the treatment provided (apart from referral situations). However, in the interests of maintaining good professional relationships this information may be shared with the client's permission.
Veterinarians are expected to communicate professionally and not hinder the ongoing management of cases. The patient's welfare and the public perception of the profession must not be compromised by poor communication between veterinarians.
Veterinarians must not contact clients to try to discourage them from seeing another veterinarian. However conducting a professional 'client exit interview' to establish the reasons for switching to another veterinarian may be appropriate as a tool for learning and business improvement if carried out:
in a way that is not perceived by the client as pressure to return to the first practice; and
takes place at an appropriate future time.