15.14.01.10

.10 Record Keeping.

A. For animals that a veterinarian treats, the veterinarian shall prepare a legibly written record that accurately and thoroughly reflects the treatment provided. At a minimum, the veterinarian's record shall include the following information, as applicable:

(1) If available, the name, address, and phone number of the animal's owner;

(2) If available, the name and identity of the animal;

(3) If available, the age, sex, and breed of the animal;

(4) The dates (beginning and ending) of custody of the animal;

(5) A short history of the animal's condition as it pertains to the animal's medical status;

(6) The animal's physical condition at the beginning of custody and the initial diagnosis, if any;

(7) The animal's condition, as evidenced through a physical examination, not more than 12 hours before administration of one of the following:

(a) Anesthetic;

(b) Injectable sedative; or

(c) Injectable tranquilizing agent.

(8) The treatment provided the animal and if medication is given, the following shall be provided:

(a) Amount in milligrams or the volume and concentration of substance used;

(b) Frequency; and

(c) Route of administration;

(9) The progress and disposition of the case; and

(10) The surgery log and anesthetic log, if any.

B. The veterinarian shall record the information referenced in §A of this regulation in a timely manner, that is, as soon as practicable after the veterinarian has seen the animal.

C. If the veterinarian discovers that the record is incomplete or in error, the veterinarian shall amend the record, being sure to date and initial the amendment.

D. A veterinarian shall label each radiograph and any other diagnostic image or picture with the hospital, clinic, or veterinarian's name, the patient's name, the owner's name, and the date the image or picture was taken.Diagnostics include, but are not limited to, the following:

(1) Ultrasound;

(2) Magnetic resonance imaging (MRI);

(3) Computed tomography (CT) scans; and

(4) Any other device that is used to generate an image of a patient.

E. Patient records shall be kept by a veterinarian for 3 years after a patient's last visit.

F. Patient Records.

(1) Patients' records are the property of the veterinary practice for whom the records were made.

(2) If requested by a patient's owner, the veterinarian shall release a copy of an animal's written record to the owner or a subsequent treating veterinarian. The veterinarian may require the owner to pay the reasonable cost of providing the records requested.

(3) If requested by a patient's owner, the veterinarian shall release temporarily to a subsequent treating veterinarian the original nonwritten record of the animal, such as, but not limited to, radiographs, photographs, electrocardiograms, and slides. The subsequent treating veterinarian shall return these original nonwritten records within 30 days of their receipt or such other time as agreed to by the parties.

(4) Upon request and if known, a veterinarian shall inform a boarding facility, including a veterinary hospital offering boarding services, which is boarding a veterinarian's patient, whether the animal's vaccinations are current.

G. The requirements of this regulation apply to companion pet animals only.