Record Keeping for the Veterinary Practice

All veterinary practices must comply with record-keeping requirements related to the practice of veterinary medicine. In order to do so, veterinarians must be up-to-date on the various record-keeping laws imposed upon them.

American Veterinary Medical Association (AVMA) Rules

The AVMA’s Principles of Veterinary Medical Ethics requires veterinarians to keep medical records if a veterinary-patient relationship (VCPR) exists. The AVMA recommends that veterinarians maintain patient records for a minimum of two (2) years. In Georgia, a veterinarian is required to keep patient records for at least three (3) years.

Information that is required to be kept includes the name, address, and telephone number of the veterinarian and patient, and identification of the animal treated. A veterinarian is also required to keep very good records of any drugs that may be used or prescribed for treatment.

Federal Record-Keeping Laws

There are specific Drug Enforcement Administration record-keeping requirements for controlled substances. Veterinarians, when distributing a controlled substance, must keep a record of the substance name, dosage form, quantity and number of commercial containers distributed or received, date, name, address, and DEA registration number of distributing practitioner and receiving practitioner.

These records must be maintained separately and be readily accessible for a minimum of two (2) years. A veterinarian may be subject to civil or criminal sanctions for failure to maintain and produce these records.

Georgia State Board of Veterinary Medicine Requirements                     

700-12-.04 Record Keeping – Complete, accurate, and legible records must be maintained on all animals. This information must include, but is not limited to, animal owner information, animal identification, and veterinary care. Under the Board’s rules, when a veterinarian dispenses a drug, a written record must be kept. The veterinarian must produce for a patient a copy of these records, if requested. 

700-8.01 Unprofessional Conduct – A veterinarian is required to prepare and maintain a record of the care and treatment of all animals treated in the practice. These records should contain clinical information sufficient to justify the diagnosis given and to warrant the treatment given to the animal.

These records must be kept in a readily retrievable form, and recorded contemporaneously, following treatment of the animal. Copies must be made available to the animal’s owner upon their written request. A reasonable fee may be charged for the search, retrieval, duplication and mailing of the records. Failure to keep records constitutes unprofessional conduct.

Sanctions by the Georgia Board for failure to provide records

If The State Board of Veterinary Medicine office receives a complaint against a veterinarian for failure to release records, the Board will send a letter to the veterinarian to release the records to the patient within 10 days of the Veterinarian’s receipt of the Board’s letter. The veterinarian must submit proof that the records have been mailed to the patient.

If the Board does not receive proof that the records have been mailed or a response from the veterinarian within 15 days from the date the request was mailed from the Board, the veterinarian may have his or her license sanctioned by the Board with a public reprimand, which becomes a permanent part of the veterinarian’s record and possibly pay a fine of $500.00.

Record-Keeping Checklist

– Make records contemporaneous with observations and treatment

– Note client decisions to not follow recommendations

– Treatments and diagnostics offered, and reasons for each

– Phone conversations regarding treatment

– Entries made in periods of absence or vacation

– Informed consent in writing to procedures, with a witness

– Instructions about drugs for food-producing animals with withdrawal periods

Conclusion

In order to minimize legal risk associated with practicing veterinary medicine, veterinarians should keep required documentation in proper order. Keeping well-kept records will reduce the risk of errors or omissions in records, miscommunication with patients, noncompliance, and any possible claim of negligence or malpractice on the part of the veterinarian. Well-kept records can be accomplished with a reliable entry system and a well-trained veterinary staff.