| (a) A veterinarian performing a physical examination,
diagnosis, treatment or surgery on an animal or group of animals shall
prepare a legible written record or computer record concerning the
animals containing, at a minimum, the following information:
(1) name, address, and telephone number of the owner;
(2) identity of the species, animal, herd, or flock;
(3) except for herds or flocks, the age, sex, color,
and breed;
(4) dates of examination, treatment and surgery;
(5) brief history of the condition of each animal,
litter, herd, or flock;
(6) examination findings, if required for diagnosis
or treatment and is not difficult to obtain:
(A) weight - actual or estimated;
(B) temperature;
(C) pulse;
(D) respiration; and
(E) any additional findings needed for diagnosis;
(7) laboratory and radiographic tests performed and
reports;
(8) differential diagnosis; referrals/consultations;
to/with specialists and the client’s response;
(9) procedures performed/treatment given and results;
(10) drugs (and their dosages) administered, dispensed,
or prescribed;
(11) surgical procedures shall include a description
of the procedure, the name of the surgeon, the type of sedative/anesthetic
agent used, the route of administration and the dosage; and
(12) anesthesia monitoring performed during surgical
procedures.
(b) Individual records must be maintained on each patient,
except that records on livestock or litters of animals may be maintained
on a per-client basis. Records pertaining to these animals may be
kept in a daily log or billing records, provided that the treatment
information is substantial enough to identify these animals and the
medical care provided.
(c) Medical records and radiographs are the physical
property of the hospital or the proprietor of the practice that prepared
them. Records, including radiographs, must be maintained for a minimum
of three years after the last visit.
(d) Medical records shall be released upon request
from a treating veterinarian with a legitimate interest, and shall
be returned to the originating practice within a reasonable time if
requested. Copies of records must be made available upon request from
the owner of an animal at a reasonable cost to the owner and within
a reasonable time. A veterinarian may not withhold the release of
veterinary medical records for nonpayment of a professional fee.
(e) All regulated substances shall be recorded as required
by federal and/or state regulations.
(f) Any signed acknowledgement required by §§573.14
and 573.16 - 573.18 (relating to all complementary therapies).
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| 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; amended to be effective August 16, 2022, 47 TexReg 4853 |
