Section 31.22. Recordkeeping

Veterinary medical records serve as a basis for planning patient care and as a means of communicating among members of the veterinary practice. The records furnish documentary evidence of the patient’s illness, hospital care and treatment and serve as a basis for review, study and evaluation of the care and treatment rendered by the veterinarian. A veterinary medical record shall be kept in a problem-oriented or similar format that allows any veterinarian, by reading the record, to proceed with the care and treatment of the patient and allow the Board or other agency to determine the advice and treatment recommended and performed. This section does not apply to laboratory animal practice.

(1) Record required. A veterinarian shall maintain a separate veterinary medical record for each patient, herd or group, as appropriate, which accurately, legibly and completely reflects the evaluation and treatment of the patient or patients. The veterinary medical record must identify the treating individual after each chart entry.

(2) Identity of patient. The veterinary medical record must include, at a minimum, the following information to identify the patient, herd or group:

(i) Client identification.

(ii) Appropriate patient identification, which may include species, breed, age, sex, weight, name or identity number or numbers, color and identifying markings, and whether neutered, spayed or intact.

(3) Minimum content of record. Production animal veterinarians shall comply with all Federal recordkeeping requirements, including requirements in 9 CFR (relating to animals and animal products). Veterinary medical records for other animals must include:

(i) Vaccination history.

(ii) Previous medical history, presenting symptoms and complaint.

(iii) Date of each examination.

(iv) Diagnosis.

(v) Results and findings of pathological or clinical laboratory examination.

(vi) Findings of radiological examination.

(vii) Medical or surgical treatment.

(viii) Other diagnostic, corrective or therapeutic procedures.

(ix) Documentation of drugs administered, prescribed or dispensed, including dosage.

(x) Documentation of surgical and dental procedures, including type and dosage of anesthesia, and dental charting.

(4) Communication with client. The veterinary medical record of any patient, except a production animal, must document communication with the client, including the client’s consent to or rejection of recommended diagnostic tests, treatments and drugs.

(5) Retention of records. Records shall be maintained for a minimum of 3 years from the date that the patient was last treated by the veterinarian.

(6) Ownership and use of records. The records of a veterinary practice are the sole property of that facility, and when a veterinarian leaves salaried employment therein, the departing veterinarian may not copy, remove or make subsequent use of the records, without the consent of the owner of the veterinary practice.

(7) Radiographs. A radiograph is the property of the veterinary practice that originally ordered it to be prepared. Radiographs shall be properly identified by hospital name, date, name of client, name of patient and positional marker. A radiograph shall be released upon the written request of another veterinarian who has the written authorization of the client. The radiograph shall be returned to the veterinary practice that originally ordered it to be prepared within a reasonable time.

(8) Release of information to clients. A veterinarian shall release a summary or a copy of the veterinary medical records of a patient to the client within 3 business days of receipt of the client’s written request. A veterinarian may charge a reasonable fee for duplicating veterinary medical records and for preparation of veterinary medical record file summaries for release to clients. A veterinarian may not withhold the release of veterinary medical records or summaries to clients for nonpayment of a professional fee. The release of veterinary medical records or summaries to clients under these circumstances does not constitute a waiver by the veterinarian of the fee claimed.

(9) Veterinary medical records for vaccination clinics. A veterinarian providing veterinary medical services to the public for a public health vaccination clinic or an animal health vaccination clinic shall prepare a veterinary medical record that includes, at a minimum, an identification of the client and patient, the vaccine lot number, and the date and dosage administered. A veterinarian who provides veterinary medical services to a vaccination clinic shall provide a means for clients to obtain advice pertaining to postvaccine reactions for the 24-hour period immediately following the time of vaccination.

(10) Veterinary records of retiring veterinarian or a veterinary practice that is closing. A veterinarian shall notify clients, in writing, at least 30 days prior to the date of a planned retirement or closing of a veterinary practice. The written notice must include instructions on how to obtain copies of veterinary medical records from the veterinarian or other custodian of the records and the name, address and telephone number of the person purchasing the practice, if applicable. Veterinary medical records must remain available to clients for 3 years after the date the veterinarian retires or the practice is closed. If prior notice could not be provided, a successor veterinarian shall notify clients within 60 days of the date the successor takes over the practice.

The provisions of this § 31.22 adopted May 20, 1994, effective May 21, 1994, 24 Pa.B. 2611; amended July 13, 2007, effective July 14, 2007, 37 Pa.B. 3240. Immediately preceding text appears at serial pages (309619) to (309620).

Notation

Authority

The provisions of this § 31.22 amended under section 27.1 of the Veterinary Medicine Act (63 P. S. § 485.27a).

Cross References

This section cited in 49 Pa. Code § 31.21 (relating to rules of professional conduct for veterinarians).