| (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.
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