5 signs it’s time to upgrade your clinic’s documentation workflow
Good documentation is an essential pillar of quality veterinary care, but for many small-to-mid-sized practices, the documentation process can easily become burdensome.
Whether it’s late-night SOAP notes, lost follow-ups, or staff buried in admin tasks, outdated workflows can quietly drag clinics down.
According to the 2023 Merck Veterinary Wellbeing Study, time pressure is one of the leading contributors to burnout among veterinary professionals, and the last thing any practice needs is to lose valuable time and resources with poor documentation workflow.
Here are five signs that your current documentation workflow might be holding you back and some tips on how to help fix the problem.
1. You’re still charting after hours
With days filled with patient after patient, it can be difficult to find time to do all of the necessary charting, follow-up, and necessary administrative tasks during a normal work day. But finishing patient notes throughout the evening is a red flag not a badge of honor.
Routinely taking this work home destroys work-life balance by cutting into time for rest, family, and self care. Over time, it contributes to burnout, mental fatigue, and even clinical errors.
It’s one thing to have to finish charting after hours occasionally after an unusually hectic day, but if it is a regular occurrence, it’s a clear indicator that your workflow is inefficient and ineffective.
2. You’re missing key clinical details
When time is limited, it’s easy to want to rely on memory or shorthand to document visits. Unfortunately, this can often inadvertently lead to incomplete or inconsistent records.
Rushed or unclear notes takes its toll on continuity of care, especially if there are multiple veterinarians at your practice, and team members may need to double back for clarification, increasing the risk of miscommunication and compliance issues. Detailed and accurate records are essential for patient safety and legal protection from claims of negligence and malpractice.
If your team is frequently double-checking charts or questioning treatment plans, your documentation system isn’t supporting your clinical quality.
3. Your staff is bogged down by admin work
It’s easy to allow documentation duties to spill over to techs, receptionists, or other vets, but this only amplifies the issue by diluting everyone’s time. Instead of focusing on patient care, staff get pulled into data entry or fixing incomplete records. This not only reduces practice efficiency but also wastes valuable skilled labor.
If your team is spending as much time at the computer as they do with patients, it could be a sign that it is time to reassess your workflow.
4. You’re struggling to keep up with client communication
A disconnected system creates friction between internal documentation and external communication. That can mean missed follow-ups, unsent reminders, and frustrated pet parents.
Inconsistent client communication erodes trust and risks client turnover as pet owners seek care elsewhere.
Your documentation isn’t doing its job if you’re manually emailing summaries or fielding repeated questions about what happened in the exam room.
5. You’ve outgrown your current system
Growth problems might be good problems to have, but they’re still problems. Maybe what worked for your two-provider team no longer supports your growing caseload or multiple locations.
Older systems or rigid templates can’t flex with your growth. You might notice longer onboarding times, inconsistent note styles between providers, or limited data reporting capabilities.
If you’re constantly fielding concerns from team members or discovering new cracks in your documentation process, it’s a sign that your system can’t keep up.
How to evaluate a new documentation tool
Searching for a new documentation tool can be overwhelming. Here are a few questions to consider while assessing whether or not it’s a good fit.
- Does it reduce after-hours charting? Look for tools that simplify or speed up SOAP notes during the appointment. A tool that requires time after isn’t helpful to keeping workflows on track.
- Will it improve note quality and consistency? Tools that utilize templates, voice capture, and structured data entry can support better, more uniform documentation. These all help reduce human error.
- Can it support your team without adding complexity? Your staff is busy. Any tool should reduce friction, not add to it.
- Does it integrate with your PIMS or client communication tools? Seamless integration ensures smoother workflows and better client follow-up. The last thing you want is to have to change other systems and tools just to make a documentation tool work.
- Will it scale with your clinic’s growth? Make sure the tool can adapt as your team expands or your services evolve. This ensures that it is a long-lasting solution and not just a short-term fix.
This goes beyond buying software. It’s investing in your team’s well-being, your clinic’s efficiency, and your patients’ care. If your current system is draining your team and compromising care, it’s time to consider a smarter approach.
By recognizing the signs and asking the right questions, you can find a documentation solution that brings balance back to your clinic—and gives you more time to focus on what matters most: your patients, your people, and your peace of mind.
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