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
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.
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