Guidelines of the Veterinary Practitioners Registration Board of Victoria
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Guideline 7 - Veterinary medical records

This guideline outlines the appropriate standard expected of a registered veterinary practitioner in the course of veterinary practice. It should be read in conjunction with other related guidelines.

Context to Guideline 7: Veterinary medical records

Veterinary medical records provide:
  1. documentary evidence of the assessment, care, diagnosis, illness, and treatments or management plans provided to for an animal over time, and the communications relating to the provision of these veterinary services
  2. a means of sharing an animal clinical history between professional peers and the veterinary team within a veterinary facility or workplace
  3. a source of information for other veterinary practitioners who may care for or treat the animal
  4. a record of the scheduled drugs used or supplied for the treatment of an animal and the reason for the use or supply
  5. a basis for review and evaluation of the veterinary services delivered to the animal
  6. a record of events in any legal proceedings and/or investigation into professional conduct or fitness to practise conducted by the Board.

Veterinary medical records must satisfy all relevant legislative requirements for their content, retention and disclosure. For example, the use, supply and administration of scheduled medications must be recorded in accordance with requirements of the Drugs, Poisons and Controlled Substance Act 1981.

The guidance presented here applies whether the veterinary service occurs in the clinic, an ambulatory service or remotely through methods such as telemedicine consultation.

A veterinary practitioner should arrange transfer of veterinary medical records to another veterinary practitioner in the event that the veterinary practice owning the veterinary medical records closes or the owner requests transfer to another veterinary practitioner.

A veterinary medical record is the property of a veterinary practice or veterinary practitioner who has created or contributed to it. A veterinary practitioner is not legally required to provide copies of their veterinary medical records for an animal to its owner if there is a reasonable justification not to do so. The refusal by a veterinary practitioner to provide an owner with an animal's veterinary record is not sufficient grounds on its own for the Board to investigate an allegation of professional conduct.

If formally requested by an owner, a veterinary practitioner should provide a copy of the veterinary medical record to another veterinary practitioner if the owner is seeking a second option or if the owner wishes to nominate another veterinary practitioner to take over the ongoing care of their animal. The receiving veterinary practitioner should obtain consent from the original veterinary practitioner before providing them to an owner.

A veterinary medical record should be prepared for wildlife and stray animals and should identify, as best as possible, the animal, and the procedure, treatment or veterinary service provided to the animal. For wildlife, the record should include the location where the animal was found.

Professional conduct under this guideline is demonstrated by the following:
7.1 A veterinary practitioner ensures that the veterinary medical record contains sufficient information to:
  1. clearly identify the animal
  2. list and justify alternative treatments/procedures or management approaches
  3. record discussion with the owner on the risks associated with each recommended treatment/management option
  4. record the clinical management of the animal, and
  5. enable a professional peer to continue the care and treatment of that animal (if needed).
7.2 A veterinary practitioner takes reasonable steps to ensure their entries to a veterinary medical record are completed at the time they provide veterinary services. 
7.3 A veterinary practitioner enters information in the veterinary medical record in an accessible, complete, accurate and legible format.
7.4 A veterinary practitioner ensures that the veterinary medical record contains (as relevant) the following information:
  1. details that identify the owner of the animal and/or their designated representative, including name, address, contact number
  2. the date that the animal is examined and/or receives veterinary treatment
  3. details that may identify the animal including its species, breed, colour, age, name, tag number and/or any microchip (as relevant)
  4. the history that led to the animal being presented to the veterinary practitioner and any other relevant historical information
  5. details of the physical examination of the animal, including any and all observations and findings whether normal or abnormal
  6. other clinical observations made during the examination
  7. details of any diagnosis whether provisional, final or other
  8. details of discussions with the owner (throughout the period veterinary services are delivered) about treatment/management options, including the limitations, risks and costs of those options
  9. the treatment option(s) chosen by the owner, including the reasoning as to why that choice was made
  10. details of any ongoing care and future management plans as discussed with the owner
  11. any financial constraints substantively impacting the owner’s treatment/management decisions
  12. signed consent forms including informed consent for treatment and informed financial consent
  13. progress notes for hospitalised patients at each and every point of assessment
  14. details of all discharge instructions provided to the owner after an animal’s discharge from a veterinary facility where they were hospitalised
  15. signed veterinary certificates (where relevant)
  16. relevant clinical records such as:
    • images and imaging reports that communicate opinions and/or findings following a professional assessment of that imaging
    • laboratory reports
    • necropsy reports
    • specialist reports/referral reports
    • surgical records
    • anaesthetic records
    • dental records
    • hospitalisation records.
7.5
 A veterinary practitioner ensures veterinary medical records for a food producing animal describes and states the withholding period that must be observed for the animal before it is slaughtered or its products used (e.g. eggs, milks, etc.) for human consumption.
7.6 Except as otherwise required at law, a veterinary practitioner maintains the confidentiality of the owner’s personal and/or health information collected while providing veterinary practice.
7.7
 A veterinary practitioner responds in a timely, complete and accurate manner to a request from the Board for information contained in veterinary medical records. 
7.8
 A veterinary practitioner provides copies of an animal’s veterinary medical records or a summarised clinical history to the owner or their designated representative on request. Where in particular circumstances a veterinary practitioner determines not to meet such a request, they effectively communicate their reason for not providing the records to the owner or their designated representative.
7.9
 The owner has a responsibility to support the accuracy of the veterinary medical record by providing accurate information about their animal’s history and wellbeing to a veterinary practitioner.
7.10 In sharing the responsibility for the wellbeing of the animal receiving veterinary services, the owner has a responsibility to seek additional information if they need clarification or require alternative options to the proposed approach. A veterinary practitioner places details of such a discussion in the animal's veterinary medical record.

Related guidelines

Related legislation

Date of publication
In effect from 1 May 2021.

This material is current only at the time of publication and may be changed from time to time. The Board reviews and updates the Guidelines on a continuous basis to reflect changes in the science and knowledge base underpinning contemporary veterinary practice. The Board will take reasonable steps to inform the veterinary profession when such updates are released but it remains the responsibility of the individual veterinary practitioner to ensure that their knowledge and application of these Guidelines to their own practice is current.

While the Board has made every effort to ensure that the material in these Guidelines is correct in law, it shall not be liable to any veterinary practitioner or any other person or entity in relation to any claim, action or proceeding whatsoever (whether in contract, negligence or other tort or in proceedings seeking any other form of legal or equitable remedy or relief) for any inadequacy, error or mistake, or for any deficiency in the whole or any part of this document (including any updates incorporated in the document from time to time). A veterinary practitioner or any other person or entity acting upon the contents of this document acknowledges and accepts that this is the basis upon which the Board has produced these Guidelines and made them available to such person or entity.