What Patient Record Retention Guidelines Exist For Veterinary Offices?
The American Veterinary Medical Association (AVMA) requires veterinary clinics to keep medical records for all veterinary-patient relationships (VCPR). The AVMA recommends holding onto patient records for a minimum of two years. The minimum retention period varies from one state to the next. In Texas, the retention requirement is five years from the anniversary date of the date of last treatment.
Veterinary practices should keep the name, address, and telephone number of the patient in the patient's file as well as identification information about the animal. The file must also include detailed records of any drugs that the veterinarian prescribes or recommends for treatment. For example, the vet may suggest an over-the-counter topical cream that is available in major drug stores, and as such, will not write a prescription for it. This medication suggestion should still be documented.
Controlled Substance Record Retention Guidelines
The Drug Enforcement Administration (DEA) has its own set of record keeping guidelines for controlled substances. When a veterinarian distributes a controlled substance, he must document the name of the substance, dosage, quantity, and number of commercial containers that were distributed or received. The record must also include the date and the name, address, and DEA registration number for both the distributing and receiving practitioners.
All controlled substance records must be kept separate from other patient records and must be readily accessible for a minimum of two years. A veterinarian who fails to maintain and produce these records properly and in a timely fashion may be subject to civil or criminal sanctions.
Veterinarian Record Protocol
It is recommended that veterinarians keep detailed accounts of the following:
- All observations and treatments
- Client decisions not to follow recommended protocol
- The treatments and diagnostics that were given, including why they were given
- All phone conversations related to treatments
- Any notable happenings during periods of absence or vacation
- Informed consent for procedures, which should be documented in writing with a witness present
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