Veterinary medical records serve as a basis for
planning patient care and as a means of communicating among members of the
veterinary practice. The records furnish documentary evidence of the patient's
illness, hospital care and treatment and serve as a basis for review, study and
evaluation of the care and treatment rendered by the veterinarian. A veterinary
medical record shall be kept in a problem-oriented or similar format that
allows any veterinarian, by reading the record, to proceed with the care and
treatment of the patient and allow the Board or other agency to determine the
advice and treatment recommended and performed. This section does not apply to
laboratory animal practice.
(1)
Record required. A veterinarian shall maintain a separate
veterinary medical record for each patient, herd or group, as appropriate,
which accurately, legibly and completely reflects the evaluation and treatment
of the patient or patients. The veterinary medical record must identify the
treating individual after each chart entry.
(2)
Identity of patient. The
veterinary medical record must include, at a minimum, the following information
to identify the patient, herd or group:
(i)
Client identification.
(ii)
Appropriate patient identification, which may include species, breed, age, sex,
weight, name or identity number or numbers, color and identifying markings, and
whether neutered, spayed or intact.
(3)
Minimum content of
record. Production animal veterinarians shall comply with all Federal
recordkeeping requirements, including requirements in
9 CFR (relating to
animals and animal products). Veterinary medical records for other animals must
include:
(i) Vaccination history.
(ii) Previous medical history, presenting
symptoms and complaint.
(iii) Date
of each examination.
(iv)
Diagnosis.
(v) Results and findings
of pathological or clinical laboratory examination.
(vi) Findings of radiological
examination.
(vii) Medical or
surgical treatment.
(viii) Other
diagnostic, corrective or therapeutic procedures.
(ix) Documentation of drugs administered,
prescribed or dispensed, including dosage.
(x) Documentation of surgical and dental
procedures, including type and dosage of anesthesia, and dental
charting.
(4)
Communication with client. The veterinary medical record of
any patient, except a production animal, must document communication with the
client, including the client's consent to or rejection of recommended
diagnostic tests, treatments and drugs.
(5)
Retention of records.
Records shall be maintained for a minimum of 3 years from the date that the
patient was last treated by the veterinarian.
(6)
Ownership and use of
records. The records of a veterinary practice are the sole property of
that facility, and when a veterinarian leaves salaried employment therein, the
departing veterinarian may not copy, remove or make subsequent use of the
records, without the consent of the owner of the veterinary practice.
(7)
Radiographs. A
radiograph is the property of the veterinary practice that originally ordered
it to be prepared. Radiographs shall be properly identified by hospital name,
date, name of client, name of patient and positional marker. A radiograph shall
be released upon the written request of another veterinarian who has the
written authorization of the client. The radiograph shall be returned to the
veterinary practice that originally ordered it to be prepared within a
reasonable time.
(8)
Release of information to clients. A veterinarian shall
release a summary or a copy of the veterinary medical records of a patient to
the client within 3 business days of receipt of the client's written request. A
veterinarian may charge a reasonable fee for duplicating veterinary medical
records and for preparation of veterinary medical record file summaries for
release to clients. A veterinarian may not withhold the release of veterinary
medical records or summaries to clients for nonpayment of a professional fee.
The release of veterinary medical records or summaries to clients under these
circumstances does not constitute a waiver by the veterinarian of the fee
claimed.
(9)
Veterinary
medical records for vaccination clinics. A veterinarian providing
veterinary medical services to the public for a public health vaccination
clinic or an animal health vaccination clinic shall prepare a veterinary
medical record that includes, at a minimum, an identification of the client and
patient, the vaccine lot number, and the date and dosage administered. A
veterinarian who provides veterinary medical services to a vaccination clinic
shall provide a means for clients to obtain advice pertaining to postvaccine
reactions for the 24-hour period immediately following the time of
vaccination.
(10)
Veterinary records of retiring veterinarian or a veterinary practice
that is closing. A veterinarian shall notify clients, in writing, at
least 30 days prior to the date of a planned retirement or closing of a
veterinary practice. The written notice must include instructions on how to
obtain copies of veterinary medical records from the veterinarian or other
custodian of the records and the name, address and telephone number of the
person purchasing the practice, if applicable. Veterinary medical records must
remain available to clients for 3 years after the date the veterinarian retires
or the practice is closed. If prior notice could not be provided, a successor
veterinarian shall notify clients within 60 days of the date the successor
takes over the practice.
