Veterinary medical records requirements
Published in the April 2021 issue of Vetboard Victoria's newsletter
The Board has recently considered several matters where records of an animal’s consultation and treatment, AND communication with the owner, were either incomplete or not made at all.
While this issue has previously been raised in regard to small animal practice, the Board has noted that this issue is occurring more frequently in large animal practice, in particular equine practice.
A record of matters discussed with the owner is essential – for example treatment options offered, potential side effects and possible prognosis. Without such records, the Board is unable to assess what discussions with the owner have occurred and what evidence to rely on when considering professional conduct matters.
On 1 May 2021, incoming Guideline 7 – Veterinary medical records will take effect. Item 7.1 in this Guideline will require veterinary practitioners to ‘ensure that the veterinary medical record contains sufficient information to:
- clearly identify the animal
- list and justify alternative treatments/ procedures or management approaches
- record discussion with the owner on the risks associated with each recommended treatment/management option
- record the clinical management of the animal, and
- enable a professional peer to continue the care and treatment of that animal (if needed).’
Under Guideline 7, veterinary practitioners will also be required to take ‘reasonable steps to ensure their entries to a veterinary medical record are completed at the time they provide veterinary services.’
While the Board appreciates that many large animals may be treated away from a practice at an owner’s premises, it is important that a veterinary practitioner completes a comprehensive medical record while consultation and treatment of the animal are fresh in the practitioner’s mind, either on site (using electronic aids) or as soon as possible after returning to the practice. Mobile veterinary practices are subject to the same requirements and should have record-keeping systems in place which will allow them to comply with Guideline 7.
Guideline 7.4 sets out the information that the Board expects to be included in a veterinary medical record (from 1 May 2021). Note that anaesthetic records form part of expected clinical records. In several cases the Board has considered recently, anaesthetic records have not been kept or have been inadequate.
For the period up to 1 May, current Board guideline 11.1.2 applies, ‘Veterinary practitioners must ensure that veterinary records contain sufficient information to clearly identify the animal(s) and justify the clinical management and treatment.’ See Guideline 11.1.3 for the information the Board currently expects to be included in a record.
Relevant guidelines