Veterinary records

This guideline describes the minimum standard expected from a registered veterinary surgeon exercising reasonable skill and care in the course of practising veterinary science. It should be read in conjunction with relevant Queensland legislation and other guidelines and definitions.

Veterinary patient records provide a contemporaneous record of the veterinary management of an animal. They serve as an important basis for review and evaluation of veterinary care and are essential for the continuity of care of the patient.

Complete patient records are the most important part of a veterinarian’s defence against a complaint.

Legislative requirement

Section 24 of the Veterinary Surgeons Regulation 2016, details the legal requirements for patient records.

Veterinarians must keep patient records for 3 years from the day the last information about the animal is included in the record.

Content of a veterinary patient record

The Board requires records to be patient-centric and expects the following details to be recorded:

• identification of client and patient
• signalment
• date of entry and identification of the veterinarian
• presenting problem
• relevant history
• physical examination findings – a comprehensive physical examination is expected to be recorded by body system to the extent relevant to the veterinary management of the patient.
  • Basic objective parameters from a physical examination should be recorded – these should include, where relevant, body condition score and/or weight, heart rate, respiratory rate, temperature, mucous membrane colour and capillary refill time.
  • The use of eye, dental and skin charts is recommended.
  • Acronyms like NAD (no abnormality detected) and WNL (within normal limits) are acceptable against a body system examined, however using these for a full physical examination is not acceptable (e.g. PE NAD).
  • Any limitations of the physical examination should be recorded.
• Clinical reasoning must be evident in patient records including:
  • differential diagnoses/diagnosis
  • case management plan – approach to further investigation and treatment
  • updated as required to reflect developments in case management over time.
• Evidence of client communication and informed consent (see separate guidelines). Communication with the client while under veterinary management must be regular and documented.
• Details of:
  • diagnostic procedures, images (radiographs/ultrasound/other), clinical pathology results, findings and interpretation
  • full description of any procedure including but not limited to surgeries, treatments and anaesthetic records if applicable
  • medications administered including dose and route.
• Details of any instructions given when the patient is discharged. The use of written discharge instructions is recommended. The instructions should be fully explained to the client.

In addition to the full patient record details expected above, a patient record also includes where applicable:

• admission/consent forms
• cage cards, hospital charts and any other hand-written records
• referral reports
• certifications
• prescriptions
• billing records
• any other physical or electronic record relating to patient care.

Patient records should not be changed. If you realise at a later point that they are factually inaccurate an amendment should be added. Any correction must be clearly shown as an alteration, with the date the amendment was made and the veterinarians name.

Do not include any gratuitous comments or information that could possibly cause offence to any party in patient records.

Ownership of patient records

Patient records are the property of the attending veterinarian. Legal precedent indicates that a client does not have a legal right of access to patient records. A veterinarian has the right to decide whether to provide a copy of patient records to clients.

A decision by a veterinarian to refuse to provide an animal’s patient record to a client on request by the client – is not sufficient to justify a complaint to the Veterinary Surgeons Board.

Legal precedent

The issue of ownership of patient records has been addressed through legal challenges involving the civil court system, the Supreme Court and the Court of Appeal. On each occasion the plaintiff/appellant (the patient) said they deserved to have a copy of medical records because they had requested them.

The Supreme Court of Brisbane delivered a judgement on an appeal in Maquire v Lynch [2007] QCA 290, on 7th September 2007. The appellant was seeking an order that the respondent, a veterinary surgeon, hand over records of treatment for his animals. The Appeal was denied with the court finding the client had NO legal right of access to the patient records.

The judgement referred to an earlier ruling in Breen v Williams [1995] HCA 63; (1996) 186 CLR 71, in which the appellant, Mrs Breen, sought a declaration that she had a right to information in medical records compiled in relation to her by her treating doctor. The High Court held that under Australian common law a patient does not have a right of access to inspect and or obtain copies of his or her medical records.

Consumers of human health care services in Australia have only a limited right to their medical records, generally under Freedom of Information legislation. There are also non-statutory rights for patients to be informed of all relevant factual information contained in medical records held by a private practitioner through Australian Medical Association endorsed guidelines.

Comments about this judgement include mention that in some other jurisdictions (New Zealand, the United Kingdom, Canada and most States in the United States), consumers of health care services do have a legal right of access to their medical records.

Providing patient records to another veterinarian

If formally requested by a client, veterinarians should provide a copy of the patient record to another veterinarian if the client is seeking a second opinion or if the client wishes to nominate another veterinarian to take over the ongoing care of their animal. The receiving veterinarian should obtain consent from the original veterinarian before providing them to a client.

If a veterinarian refuses to provide patient records to another veterinarian and this results in an adverse outcome or the patient undergoes a repeat invasive procedure, the veterinarian who did not provide the patient records may be found guilty of professional misconduct.

Patient records and premises closures

In the event of a veterinary premises closure, records should be:

• retained by the veterinarian and made accessible if requested by clients for the statutory period of 3 years; or
• provided to another veterinary practice and notify clients of their location so they can organise continuity of care for their animals; or
• provided directly to clients.