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Management of Clinical Records

The ACT Veterinary Practitioners Board (the Board) requires that every registered premises have an efficient record keeping system for client records.

Veterinary Medical Records

Veterinary medical records are an important tool in the practise of veterinary medicine. They serve as a basis for planning patient care, and as a means of communication between veterinary practitioners or staff. They provide documentary evidence of the animal’s illness, care and treatment. They serve as a basis for review, study and evaluation of medical care rendered by the clinic. They form an essential record of restricted drugs used or supplied, and the basis for the supply.

A veterinary medical record may be handwritten on client cards or stored as computer information. They must be readily retrievable, legible and a complete record of all consultation between animal patient or herd/flock, owner and veterinary practitioner. Veterinary records must contain sufficient information to justify the diagnosis and treatment of the animals or herd/flock concerned. In the case of a herd/flock, the record should contain sufficient information to identify the herd/flock concerned, the problem under consideration, record all investigation results and treatments prescribed.

Any certificate issued should be recorded as part of the animal’s clinical records.

The veterinary medical records of each patient should provide the following history data:

  • Client identification;
  • Animal patient or herd identification;
  • Medical history;
  • Physical examination details;
  • Provisional and final diagnosis;
  • Treatment given, dispensed or prescribed;
  • Vaccination record;
  • Copy of any certificate issued.

And where relevant:

  • Prognosis;
  • Consultation progress notes;
  • Radiographic records;
  • Imaging reports, eg. CAT, MRI, Ultrasound, v. ECG, EEG, Scintigraphy
  • Laboratory reports;
  • Autopsy reports;
  • Specialist reports;
  • Surgical mortality record;
  • Hospitalisation treatment record.

All veterinary medical records are the property of the clinic and maintained in the clinic for the benefit of the client, the animal, the staff and the clinic. Veterinary medical records should be confidential and no information in these records should be released to anyone without clear authorisation from the owner of the particular animal.

Objective comments re an animal’s temperament may be included, eg, nervous, aggressive, fear biter, etc., however, subjective personal comments about clients or animals are inappropriate in medical records and should be avoided.

In the case of a stray, medical records should be kept identifying as best as possible the animal and the procedure.

Retention of Medical Records

Should legal action be brought against a veterinary practitioner, all documentary evidence would be brought to account and medical records are likely to be needed in defence. Records should be kept for at least four years after the last occasion on which the animal received treatment.

Access to Records

Clients are entitled to copies of relevant records. Whether or not there is a cost involved is a matter for the individual veterinary practice. Where the history is complex, an attempt should be made to discuss the case with the next veterinary practitioner. Pathology reports should include raw data and the pathologists’ analysis.

Whether the request to forward veterinary medical records is made by the client or the second veterinary practitioner, this request should be treated professionally and actioned as quickly as possible by the first veterinary practitioner. When a medical record is transferred and a copy is not kept, a note should be made of the name and address of where the information was transferred.

In the event of the sale, transfer or closure of a practice, the veterinary practitioner must decide what to do with the medical records they hold. They can elect to sell, transfer, retain or hand the information directly to the client. The practitioner is obliged to notify clients of what is going to be done with their animal’s records. Means of notification may include:

  • Publishing a notice in the newspaper. The notice should set out the details of the proposed changes in the premises and state whether the records are to be retained by the veterinary practitioner, transferred to another practitioner or made available to the clients;
  • Placing a notice in the premises. A written notice should be placed in a prominent location in the premises for a period of not less than two months prior to the date of the changes in the premises (where possible).
  • Clients with animals currently receiving a course of treatment, therapy, or being monitored by the premises, should, where practicable, be sent notification in writing about the changes to the premises.
  • As a last resort, where a premises has closed and circumstances require, the Board may determine the fate of any residual records.

Practitioners should consider in their succession and estate planning, provision for medical records they hold.

The Board can demand to see all pertinent records as part of a complaint investigation.

The courts have power to require any information that they see fit. Veterinary practitioners have a duty to comply with any lawful requests promptly and efficiently.

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We acknowledge the Traditional Custodians of the ACT, the Ngunnawal people. We acknowledge and respect their continuing culture and the contribution they make to the life of this city and this region.

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