For the Record: Keeping Medical Records

Keeping your own medical file may be one of the most important contributions you can make to your horse's health care management. From EQUUS magazine.

You select feeds carefully, you make sure your horse gets plenty of exercise and turnout time. You keep an immaculate barn, maintain your fences diligently and keep matching first-aid kits in the tack room and trailer. In short, you work hard to keep your horse safe and healthy.

But you may still be overlooking one measure vital to protecting your horse’s well-being. Your own physician couldn’t give you adequate health care without a record of your medical history and health habits. Likewise, the professionals you rely on to keep your horse sound and healthy will be able to do a better job if they have a comprehensive record of his care and maintenance.

An organized and faithfully maintained account of your horse’s vaccination schedule, injuries, past care and medications can give your veterinarian information that may make a critical difference in a crisis. A home medical file can also aid communication among multiple veterinarians and other health-care professionals who may attend to your horse. And it might help you avert an emergency by revealing otherwise too-subtle-to-notice changes in your horse over time. Finally, your medical file will enable others to step in and care for your horse as you do if a crisis of your own forces you to leave the barn for days or longer without making your customary arrangements.

Fortunately, your horse’s home medical file need not entail tedious filing or time-consuming paperwork. In fact, the simpler your system, the better. You do need to keep a certain minimum amount of information handy; beyond that, your system can be tailored to accommodate the amount of time and energy you can devote to it.

The worst thing you can do, though, is to keep it all “in your head.” You’ll never remember everything in the heat of an emergency, and you may not even be around.

Whether you are starting from scratch or upgrading your existing record-keeping system, we have some suggestions for what information to keep and how to organize it all. Choose the techniques that best apply to your situation and adapt them as necessary. Exactly how you keep records isn’t critical, but it is important that your system fit your management style so you’ll be more likely to keep it up.

What’s important?

With enough time and inclination, you could record your horse’s every sneeze and stumble. But tracking so many details isn’t necessary for records to be useful. Every horse’s basic medical record needs to include just seven types of information:

Vaccinations. A record of inoculations is the most important item to keep in your medical file. Record when your horse is due for each vaccine and have a way to confirm that it was performed-a copy of the veterinarian’s bill is one option. It’s also important to record any reactions, however mild, your horse may have had to a vaccine.

Parasite control. You’ll want to record when your horse is due for deworming, when he actually received it, and which product was used. Be sure to note how much of the active ingredient (ivermectin, fenbendazole, etc.) was used so you can rotate dewormers if necessary. A routine fecal egg count will tell you whether your deworming program is effective. If you have a count done, record the results so you can spot trends over time.

Medications. Whether it’s a daily ritual or a temporary treatment, record the drugs your horse receives and when. Also note when he misses a dose for any reason. It’s a good idea to list the brand name and manufacturer of all drugs, for reordering, and the lot number and expiration date in case of an adverse reaction.

Medical incidents. Even if you handle your horse’s minor bumps, sniffles and strains yourself, keep track of what occurred and how you responded. Seemingly unrelated episodes of minor colic, for instance, could reveal a pattern when recorded over time. Also note how long it took your horse to recover and any setbacks he may have had.

Veterinary visits. A bill is a financial record of a veterinary visit, but later on you may need to know more than just what it cost you. Make a note of why the veterinarian was called, what tests were performed, the diagnosis and treatment. Even better, ask your veterinarian to write down the key elements of the visit himself so you’ll be sure to get it right. Most will be happy to oblige.

Dental examinations. Keep a record of all dental work done on your horse, from routine floating to tooth extraction and other more complicated procedures. Ask your veterinarian to summarize each visit in writing if you’re not sure of what was done.

Farriery work. If your horse requires only routine work, your records on his hoof care can be minimal-simply note when he is due for a trim or new shoes and the work that was done. But if your horse has problem feet or is recovering from a serious hoof disorder, you’ll want to keep more detailed records. Document exactly how your farrier treated the problem, all the way down to the degree of wedge pad and how the horse reacted to it. Ask your farrier to review your notes or write down the information himself to help ensure accuracy.

Beyond the basics

In some circumstances, you may need to keep more detailed records. These types of additional information may also be useful for you:

Feeding. It may seem mundane, but a record of your horse’s regular diet and eating habits can prove useful. Note the basic elements of his daily ration, including the type and amount of hay he receives, the type and quality of the grass in his pasture, and any prepared feeds and feed supplements he receives (keep a label from a feedbag for reference). If changes are made, note when and why.

Baseline vital statistics. If your horse is healthy, taking vital statistics daily is probably unnecessary. But recording your horse’s particulars annually or even quarterly is a good idea. Be sure to take your horse’s temperature and pulse while he is resting in a cool area. Estimate his weight with a weight tape or get it exactly if you have access to a livestock scale.

Breeding records. Obviously, if you run a large-scale breeding operation, you need very specific records for both health and business purposes. If you keep only a mare or two, however, you need to note only the important events such as breeding dates, foal checks, injuries and the mare’s physical or behavioral changes. Once the foal arrives, don’t forget to start a medical file for him.

Competition and training. Even if you’re not embarking on a serious fitness program or competitive campaign with your horse, you may want to routinely jot down what type of riding you’ve been doing and note changes in your work routine. Take particular note of any long or stressful training sessions and record any setbacks, such as refusing fences or increased spookiness, that could be related to physical problems.

Environment. How and where your horse lives affects his health, sometimes in surprising ways. Having a record of where your horse is stabled or pastured and who his buddies are can provide important clues to medical mysteries. It’s especially important to document any changes in his environment, including relocation, new neighbors or physical changes, such as a repainted fence or a freshly fertilized pasture.

Behavior. Some of the most serious medical problems manifest first as behavioral quirks. If your horse suddenly begins head tossing or stall walking, for instance, make a note of when and how frequently he does it. Equally significant is a sudden absence of a behavior he’s had for years.

Pedigree. If you know your horse’s pedigree, you may want to keep a copy somewhere in his medical file. Many genetic diseases can be linked to a particular breed or family, and a quick review of ancestors can sometimes reveal the cause of a serious problem.

Keeping track of it all

If you know exactly where to find your itemized income tax returns from 1995, you’ll probably have no problem establishing or maintaining a record system for your horse’s health. If not, you may need a bit of encouragement to get started. Here are four methods, from simple to more complicated, to keep track of your horse’s health information. Start with whatever you’re sure you can do, then upgrade later if you feel more ambitious.

Daily calendar. This method makes it easy to keep track of scheduled appointments, plus you can check off completed tasks and jot any additional notes right on the calendar. Any simple calendar-wall hanging or a day planner-will suffice as long as there is room for adequate notes. At the end of the year, keep the calendar. This method is simple and quick, but you’ll be short of room for long or complicated notes, so you may need to make addendums.

Index cards. A pack of index cards and a box to hold them make a simple filing system. Use dividers for different categories, such as vaccinations or shoeing, and dedicate individual cards to specific treatments or visits. Just make sure you note dates on the cards and file them in the right location. This method works well if you have several horses-simply make a box for each one.

Loose-leaf notebook. A three-ring binder can hold a calendar, folders, zippered pouches, dividers and enough paper to keep track of a barnful of horses, with many options for organization. You can create divided sections for each horse or for specific categories. With a little creativity, you can use graph paper to track vaccinations and deworming treatments for all your horses on a single sheet. A notebook allows you to keep all your information, plus reminders, in a single location and provides space to file copies or odd-size documents.

Computer. Depending on your comfort level with technology, computerized record keeping may be a perfect solution. A wide variety of software is available for the job. You can choose from customized horse record-keeping programs or adapt general office software for your needs. With the proper tools, you can also keep and send images, such as radiographs, to specialists. Computers do have their downside, however: Unless you keep yours in the barn, you’ll need to remember to update your information once you get home. And there is always the risk of damaged or lost data.

Even with all the high-tech advances in veterinary medicine, there’s no substitute for a comprehensive knowledge of a horse’s medical history. In fact, keeping your own medical file may be one of the most important contributions you can make to your horse’s health care. Of course, you may be collecting information that will never be used. Or, some day, your records may reveal the one key piece of evidence that solves a baffling medical mystery and ensures your horse’s full recovery.

Photos Worth 1,000 Words

Most photos of your horse probably end up in an album or on your desk at work. But still and video images can be invaluable additions to your horse’s

medical file. If your horse is having special work done on his hooves, for instance, take a picture after each shoeing so you and your farrier can compare results over time. Likewise, a videotape of your horse can be indispensable for tracking the progress of a neurological disorder or lameness. Even if your horse is healthy, it’s a good idea to take conformation photos each year. Pose him carefully for each shot, making sure he is standing square on even ground. These pictures serve not only as identification, but also as a point reference should your horse suddenly drop weight or otherwise change physically. Be sure to mark the date on each photo or videotape.

Diagnostic Images – Mine or Yours?

X-rays, ultrasound, scintigraphy, thermography and other diagnostic technology all produce valuable information about your horse’s health, and diagnostic images and printouts are important additions to your home medical file whether you simply file them or use them to seek second opinions. However, who actually owns the documents and images produced by these tests isn’t always clear.

Veterinarians own and keep an original copy of every test and image they produce, just as photographers retain the rights to their photographs. From both a professional and a legal standpoint, veterinarians need to have immediate access to the diagnostic information those images contain. As a paying client, however, you have a legal right to purchase copies of all the images and readings concerning your horse.

You can request copies of all images after the test is run, but be prepared to wait and pay an extra charge. Copies of X rays, for instance, must be made at specially equipped clinics. A better idea is to ask for a copy before a test is run. Then the technician may be able to just load a second film in the X-ray cassette or run a second printout of a test.

This article first appeared in EQUUS magazine.




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