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RULE §573.52Veterinarian Patient Record Keeping

(a) Individual records shall be maintained at the veterinarian's place of business, shall be complete, contemporaneous and legible and shall include, but are not limited to:

  (1) name, address, and phone number of the client;

  (2) identification of patient, including name, species, breed, age, sex, and description;

  (3) patient history;

  (4) dates of visits;

  (5) any immunization records;

  (6) weight if required for diagnosis or treatment. Weight may be estimated if actual weight is difficult to obtain;

  (7) temperature if required for diagnosis or treatment except when treating a herd, flock, or a species, or an individual animal that is difficult to obtain a temperature;

  (8) any laboratory analysis;

  (9) any diagnostic images or written summary of results if unable to save image;

  (10) differential diagnosis and/or treatment, if applicable;

  (11) names, dosages, concentration, and routes of administration of each drug prescribed, administered and/or dispensed. If a drug is approved by the United States Food and Drug Administration (FDA) in only one concentration and the veterinarian is administering the FDA-approved drug at the FDA-approved concentration, the veterinarian may omit recording the concentration of the drug administered;

  (12) other details necessary to substantiate or document the examination, diagnosis, and treatment provided, and/or surgical procedure performed;

  (13) any signed acknowledgment required by §§573.14, 573.16, 573.17, and 573.18 of this title (relating to Alternate Therapies--Chiropractic and Other Forms of Musculoskeletal Manipulation, Alternate Therapies--Acupuncture, Alternate Therapies--Holistic Medicine, and Alternate Therapies--Homeopathy);

  (14) the identity of the veterinarian who performed or supervised the procedure recorded;

  (15) any amendment, supplementation, change, or correction in a patient record not made contemporaneously with the act or observation noted by indicating the time and date of the amendment, supplementation, change or correction, and clearly indicating that there has been an amendment, supplementation, change, or correction;

  (16) the date and substance of any referral recommendations, with reference to the response of the client;

  (17) the date and substance of any consultation concerning a case with a specialist or other more qualified veterinarian; and

  (18) copies of any official health documents issued for the animal.

(b) Maintenance of Patient Records.

  (1) Patient records shall be current and readily available for a minimum of five years from the date of last treatment by the veterinarian.

  (2) A veterinarian may destroy medical records that relate to any civil, criminal or administrative proceeding only if the veterinarian knows the proceeding has been finally resolved.

  (3) Veterinarians shall retain patient records for such longer length of time than that imposed herein when mandated by other federal or state statute or regulation.

  (4) Patient records are the responsibility and property of the veterinarian or veterinarians who own the veterinary practice, provided however, the client is entitled to a copy of the patient records pertaining to the client's animals.

  (5) If the veterinarian discontinues his or her practice, the veterinarian may transfer ownership of records to another licensed veterinarian or group of veterinarians only if the veterinarian provides notice consistent with §573.55 of this title (relating to Transfer and Disposal of Patient Records) and the veterinarian who assumes ownership of the records shall maintain the records consistent with this chapter.

(c) When appropriate, veterinarians may substitute the words "herd", "flock" or other collective term in place of the word "patient" in subsections (a) and (b) of this section. Records to be maintained on these animals may be kept in a daily log, or the billing records, provided that the treatment information that is entered is adequate to substantiate the identification of these animals and the medical care provided. In no case does this eliminate the requirement to maintain drug records as specified by state and federal law and Board rules.

Source Note: The provisions of this §573.52 adopted to be effective June 14, 2012, 37 TexReg 4229; amended to be effective December 23, 2013, 38 TexReg 9365; amended to be effective August 22, 2016, 41 TexReg 6203

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