Tenn. Comp. R. & Regs. 1730-02-.04 - RECORDKEEPING

(1) The following minimum standards apply to all patient recordkeeping.

(a) Records shall be maintained for a minimum of three (3) years.

(b) A separate log shall be maintained for all controlled substances.

(c) Each patient record shall indicate the strength and quantity of any medication prescribed, administered or dispensed. In the case of companion animals, this record shall be maintained for each individual animal.

(d) Records shall reflect the problems the patient presents and the veterinary interventions performed or prescribed.

(e) Records shall reflect referral of cases where further expertise or equipment is needed.

(f) A veterinarian shall comply with requests for veterinary records as required by the Medical Records provisions of T.C.A. §§ 63-2-101 to 102.

(2) Medical records for small animal facilities and practices shall be clear, legible, retrievable, and contain pertinent information such as:

(a) Name, address, and phone number of the owner/agent.

(b) Identification of patient including name, species, breed, age, sex, and description.

(c) Separate record for each patient. This record may be in a group of records for the owner/agent.

(d) Patient's vaccinations, medical and surgical history and procedures.

(3) Medical records for large animal facilities and practices shall be clear, legible, retrievable, maintained on either a herd, flock or individual basis and contain:

(a) Name, business/farm name, address, and phone number of the owner/agent.

(b) Identification of any animal(s) suspected of having a reportable disease or other disease with public health implications.

(c) Relevant medical and surgical procedures, including vaccinations given and lab reports, to the individual, group, or herd.

(d) A record of all drugs administered or dispensed, including quantity and withdrawal times.

(4) Veterinarians providing written or oral instructions for persons who are not licensed as veterinarians to perform accepted livestock management practices must record the order, including specific information on the substance of the order and the date given, in the records of the animal.

(5) For the purpose of these rules, the records shall be "owned" by the practice.

(6) Radiographs are considered to be a part of the client's records.

(7) Outside of a valid veterinarian-client-patient relationship, records from another veterinary practice may not be used as the sole basis for prescribing or dispensing medication.

Notes

Tenn. Comp. R. & Regs. 1730-02-.04

Original rule filed May 30, 1980; effective August 27, 1980. Amendment filed July 10, 1989; effective August 24, 1989. Repeal and new rule filed April 28, 1995; effective July 12, 1995. Repeal and new rule filed June 10, 1999; effective August 24, 1999. Amendment filed September 12, 2001; effective November 26, 2001. Amendment filed June 25, 2003; effective September 8, 2003. Amendment filed May 26, 2004; effective August 9, 2004. Amendment filed June 24, 2004; effective September 7, 2004. Amendment filed May 23, 2014; effective 8/21/2014.

Authority: T.C.A. §§ 4-5-202, 4-5-204, 63-2-101, 63-2-102, 63-12-105, 63-12-106, 63-12-133, and 63-12-139.