Vetspire Audit Guidelines

Description:

Auditing Vetspire is an important part of maintaining veterinary medical record integrity. This document lists the primary areas to review when conducting a Vetspire Medical Record Review. 

The medical record is critical to veterinary licensure, legal compliance, professional standards, and to ensure the communication and documentation of all aspects pertinent to the health and medical outcomes of the patient. The clinical records also serve as a legal document to explain what occurred in the medical care received and are used in board inquiries, regulatory reviews, and court cases.

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Procedure

Review the following:

• Is the team sending ETA/self check in to clients before appointment
• Is correct provider and technician chosen on encounter?
• Is the date and time correct?
• Are history and vitals filled out (if the team was able to get)?
• Is the objective, assessment, plan, client education and problem list filled out (more for DVM)?
• Are certificates being emailed or printed? Is the Rabies tag being given or mailed? - Will have to verbally ask as cannot check VS for this
• Labs being ordered correctly from encounters?
• Are tasks being created for PS for follow up exams or vaccines?
• No open invoices by accident?

All vaccine info entered?

• Dose quantity 
• Site 
• Route 
• Lot number 
• Manufacturer 
• Provider 
• Tag (if applicable for Rabies)
• Type (initial or booster) 
• Administer date 
• Next due date
• Exp date 
• State (administered or historical). Historical vaccines should only be entered in on the immunization tab at the top of the patient chart area. 
• If discontinued (for historical vaccines) 

All drug labels entered correctly?

• Dose (if applicable)
• Frequency 
• Quantity
• Refills
• Provider
• Method

Are external prescriptions being marked correctly and then either emailed or printed?

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• Estimate created through or assigned to encounter?
• Declining items in estimate so it’s recorded on encounter?
• Consent signed in estimate.
• Estimate converted to invoice from encounter.

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• Providers correct on invoices?
• Tech charging for correct items/services (exam, home visit fee, medical waste, appropriate treatments and labs, etc.)?

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• Make sure all payments were with stripe or cash?
• Encounter signed by tech or DVM when finished?
• Make sure any returns/credits were done correctly by CM?
• If another item needs to be invoiced after the client is already checked out, can re open to edit as to combine the transaction?

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• Check that vaccine reminders are correct?
• Are summaries of visits being sent to client?
• Are techs doing follow up for non wellness appointments?