The animal care industry is highly regulated and accurate and careful documentation is required. The animal and human medical worlds have quite a lot in common, especially where documentation is concerned. It is important to become aware of industry documentation. As you progress through your career, you will become familiar with and make contributions to industry documentation requirements.
What sort of paperwork is required in your job?
There are quite a few forms that require filling out regarding animal care. Some of them are official government or business forms that need to be accurately completed and lodged with the relevant agency or organisation and others are our internal forms to document things like client records, animal identification, treatment procedures and dietary intake. It is important that we complete this paperwork accurately, legibly, and promptly and store it appropriately. The documentation should be stored in a relevant filing system either by hard copy or electronically and remain confidential.
Each workplace from early childhood to construction have policies and procedures. Animal care is no different. Policies and procedures are carefully developed documents that have been written in accordance with regulations specific to the industry. There are policies and procedures in place for virtually any type of situation from privacy and confidentiality to communication. It is important you familarise yourself with the workplace’s policies and procedures they have in place. When you are first employed, it is likely you will receive a staff handout book during your induction and taken through the workplace policies and procedures. These documents will be there for you to refer to at any time when you need additional clarification.
You have been provided with a sample of a communication with clinic’s policy, click the link and familarise yourself with the purpose, context and scope of the policy. You will need to know how to identify and interpret these types of documents when you are in the workplace.
Record keeping is a form of written communication, specifically the maintenance of information that will likely be referred to at a later date.
In an animal care environment, you may be responsible for maintaining workplace records such as:
- client records
- treatment and medication notes/logs
- animal identification records
- dietary information
- training/socialisation/exercise details
- stock control
- financial records
- hygiene processes, just to name a few.
The more experience you obtain, the more familiar you will become with these workplace records and how they are used and filed. Records are important documents that often need to be kept for several years.
Good animal records are important in any animal care facility. According to the Australian Small Animal Veterinarian Association (ASAVA), Manual of Hospital Standards and Accreditation 2011 states that medical records must be kept long enough to comply with state and federal regulations and recommends 7 years.1
Keeping a copy of these records not only ensures the management of the animal’s health, but it also complies with lawful requirements which are relevant to all facilities which care for animals. In order to follow good practice, it would be wise for each individual to research specific requirements in their state/territory as some specific requirements may differ.
As you would probably imagine, there are specific record keeping guidelines that need to be considered to ensure they remain confidential and legible.
The following are guidelines for record-keeping and should always be observed.
- Handwrite legibly if using paper-based documents and complete accurate data entry when using computers.
- Include your name and signature where applicable.
- Make sure you date and, if necessary, timestamp the record.
- Be mindful of your language, remember the records may be shown to members of the public someday, avoid abbreviations if you can, and never write any insulting comments.
- Be objective, focus on facts, not speculation.
- Do not erase information that has previously been recorded, if an amendment is required simply cross out the older entry with a single line (so that it can still be read by others if need be) and write the new information next to it. Initial and potentially date the change.
- Respect privacy. If personal details are provided inform people if you need to share details with any third parties.
- Save / store records in a secure location such as a database with login/password requirements or a locked filing cabinet.
