Why is Record Keeping so important?

Record Keeping ‘What matters in court is not truth, but proof and, when I am given a case, my first question is: ‘where is the evidence?’ From my perspective, cases are won and lost on the quality of the records’.

The importance of keeping accurate records cannot be underestimated. Developments in technology and consumer rights now mean that all professionals are strongly advised to update their record-keeping skills – or risk the consequences.


You might be forgiven for thinking these statements relate to large companies and certainly not your business. However you would be wrong. Today, more than ever, we have to be able to prove what we did, why and when. Not only that, but financial records are now virtually compulsory and required to be held in electronic format. The same goes for historical records to a large extent and insurance companies "expect" electronic documented evidence.

With the latest advances in technology, other equine professionals are now starting to share imaging in particular in electronic format and many referral cases are handled via email today.

It is important to understand the principles of good record keeping, whether these records are in electronic format or paper-based, especially how it is incorporated into relationships with other professionals. Record keeping and standards of documentation are increasingly subject to close scrutiny. It is a significant fact that poor record keeping is one of the most common reasons for businesses to lose clients. More discerning clients now view good record keeping as a sign of professionalism and there can be no doubt that that the quality of record keeping is a direct reflection of the approach to, and standard of, professional practice. Similarly, where record keeping is ‘sloppy’, for example, illegible, not dated or signed, and difficult to interpret with gaps in the documented entries, this can be an indication of an equally ’sloppy’ approach to care provision.

Record keeping is an essential part of good business practice and is considered by many as a basic tool to help run the administrative affairs of the business. Good record keeping helps to protect the welfare of the horse by promoting high standards of clinical care, allowing better communication between yourself and the client including any other professionals involved in the care of the horse, giving an accurate account of treatment, and allowing the ability to detect problems at an early stage. With so many benefits, it would seem no businessman would have a problem with record keeping, but they do. Many struggle to find the time to keep good records and do not consider it as important as other activities. Hands-on care might seem more important than records, but legal experts say that if you do not put down something in your notes then legally it did not happen – making it very hard to deal with complaints.

While there is no set template or single model for record keeping, certain criteria provide the foundations for good records and best practice in record keeping. A number of these criteria relate to the style and content of documentation, and apply to both manually-held and electronic records. These should be factual, consistent and accurate - Be written as soon as possible after an event has occurred - Be written clearly and to prevent text being erased - Be written in such a manner that any alterations or additions are dated, timed and signed, allowing the original entry to still be read clearly - Be accurately dated, timed and signed - Not include abbreviations, jargon, meaningless phrases, and irrelevant speculation - Be readable on any photocopies - Be written, wherever possible, with the involvement of the client - Be consecutive - Identify problems that have arisen and the action taken to remedy them - Provide clear evidence of the care planned, decisions made, care delivered and information shared.

The selection of the best record keeping system will assure that all these criteria are satisfied allowing you to concentrate on your business and welfare of the horse.