Go with the workflow: Reimagine auditing

Medical record and invoice auditing is challenging mainly because of the lack of time, said many respondents to a recent survey on management trends from the Veterinary Hospital Managers Association.

Insufficient staffing and resources, incomplete or delayed medical records, missed or incorrect charges, human error and inconsistency, high volumes of records, and low accountability and follow-through are parts of the problem, the study showed. Many survey respondents expressed a need for a faster, easier, and more consistent auditing process; better software support; and automation or AI to reduce human error.

But answers to the auditing challenge may already be at hand.

Heather Prendergast, BS, AS, RVT, CVPM, SPHR, president of Synergie Veterinary Consulting Group, suggested reframing this work as part of the workflow, not as a separate administrative task.

“If a doctor sees a patient, there should be a complete medical record. If care is delivered, the invoice should reflect it,” Prendergast said. “Auditing is really the quality-control process around those expectations. It is a systems issue, a workflow issue, and a role clarity issue.”

She explained that auditing should not fall to one person but works best as a shared quality and patient care process with different roles owning different pieces. Medical records need medical oversight, while invoice review benefits from multiple checkpoints in the room and at checkout.

“The goal is stronger records, better consistency between providers, better defensibility, better charge capture, and better use of the hospital’s time and resources,” she said.

If problems show up across the team, for example, that usually points to a systems or training issue, she said. If an individual repeatedly misses the mark, it may call for separate coaching or a performance conversation.

“But it shouldn’t be a punitive issue. The overall tone should still be educational and improvement-focused,” she explained. “Medical records are more than a compliance obligation or a task to finish and move on from. They are a living source of information about how the hospital practices medicine, how doctors think, where communication breaks down, where follow-through is weak, and where patient care and client education can improve. In that sense, auditing is not just about catching gaps. It is also about learning from the data the hospital already has.”

Optimize your workflow

If a client reports auditing challenges, Kellie G. Olah, SPHR, CVPM, SHRM-SCP, human resource consultant for Veterinary Business Advisors, first looks at workflow on the floor. What she typically finds is a breakdown in structure and accountability and an underlying problem: workflow design and operational discipline.

“Most hospitals have policies around documentation and billing, but the issue is almost always how work is getting done in real time. When are records expected to be completed? Who ‘owns’ the record at each stage of the visit? What competing demands are pulling doctors and staff away from documentation?”

A layered approach and consistency matter far more than intensity or something separate or punitive, she suggested. For example:

• On a daily basis, quick spot checks of a small sample of records and invoices help catch issues early and reinforce expectations in real time.
• On a weekly basis, a deeper look at specific areas may find trends emerging.
• A monthly review focuses more on patterns over time. If certain errors keep repeating, leadership needs to step back and ask whether some teams are struggling more than others and whether the issue is tied to training or something in the system itself, she noted.

“When reviews only happen monthly or quarterly, they are too far removed from the actual work to change behavior. By the time issues are identified, those habits are already established. Auditing needs to be part of how the hospital operates daily.”

She recalled a few practices with issues because they audited too infrequently and didn’t notice how far behind notes were until either a DVM was leaving or a client called for records that were months old and unavailable.

She said systems like ezyVet or Vetspire and tools like PetDesk can help tighten processes, reduce missed steps, and create better visibility across the workflow. Templates, required fields, and some AI-assisted note features can help reduce missed information and standardizing records. ScribVet or Scribenote act as AI scribes and can generate notes during the appointment to decrease the time to complete records.

But technology only works if the workflow around it is clear, she said. Clear expectations need to be reflected in job descriptions, onboarding, and how people are trained so everyone is doing it the same way. If it matters, it should be part of regular feedback and reviews, not only addressed when something goes wrong. When leaders give regular feedback, it becomes part of how the hospital operates.

From reactive to proactive

Lakeview Animal Clinic in Pewaukee, Wisconsin, has seen its auditing greatly improve with a shift from reactive auditing to proactive systems, according to Practice Manager Ericka Klopp-Taipalus, CVT, CVPM.

“Using estimates as the foundation of care has been a game changer, creating alignment from the beginning, both medically and financially, so the team isn’t trying to reconstruct what happened at the end of the visit,” Klopp-Taipalus said. “Everyone is working off the same plan, and the client has full transparency.”

Instead of one person responsible for getting everything right, she explained, there are multiple checkpoints throughout the appointment and clear expectations that records are completed on the same day when possible. That has significantly reduced missed charges and improved consistency.

“When something is missed, it’s usually not because someone didn’t care, it’s because the workflow didn’t support them in that moment,” she explained, noting that’s why she focuses on making the right thing the easy thing.

Culture also plays a role, she noted, with the hospital working to create an environment where accuracy isn’t about perfection or punishment.

“It’s about supporting each other and doing right by the patient and client,” she said. “When the team understands the ‘why’ behind these processes, they’re much more engaged in following them. So, while we still have challenges like any practice, having structured systems, shared responsibility, and clear expectations has made our auditing process much more manageable and far less reactive.”

It is important to view auditing as more than just checking for missed charges or incomplete records, Klopp-Taipalus said.

“It’s an opportunity to reinforce standards across the entire practice, including how we document and communicate. Medical records should clearly tell the story of the visit, reflect all client communication, and maintain a consistently professional tone. Auditing helps ensure that standard is being upheld across every role.”

As practices grow, scalability becomes critical, she said.

“You can’t rely on memory or individual effort alone. You need structured, repeatable systems that create consistency across the team. When those systems are in place, auditing becomes less about fixing problems and more about fine-tuning performance.”

Photo credit: © AndreyPopov via iStock/Getty Images Plus

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