Policy (for practitioners)
The meaning of the term ‘veterinary science’ as defined in the Veterinary Surgeons Act includes ‘signing or issuing certificates relating to the description, health, diagnosis or treatment of animals’.
The Board’s policy is that vaccination certificates must include the practice's name, owner's name, animal's description, type of vaccine, date of vaccination and follow up instructions. The Board does not make any ruling on the form that vaccination certificates should take provided these requirements are met.
It is considered professional misconduct for a veterinarian to sign or issue in a professional capacity any certificate, notice, report or like document that is incomplete or is false or misleading in a material respect.
Giving incomplete and unsigned veterinary certificates to pet shops, breeders or practice clients for completion by the owner at time of sale of an animal is not acceptable.
Veterinary certificates, whether manually or computer generated, must be signed exclusively by registered veterinarians. Lay staff should not be put in a position where they could be prosecuted in a civil court for a breach of the Veterinary Surgeons Act.
NOTE: ‘Vaccination certificates’ signed by lay persons e.g. breeders, are not veterinary certificates. Nothing prevents a non-authorised person from vaccinating animals prior to sale with a Schedule 5 product (killed vaccine) however a certificate relating to the description, health, diagnosis or treatment of animals can only be signed and issued by a veterinarian. Schedule 4 vaccines (live vaccines) can only be administered or dispensed by registered veterinarians.
Ownership of patient history records
The Board is unable to handle complaints from the public alleging a veterinarian is refusing to provide them with their pet’s patient history records.
Patient history records are the property of the veterinarian. It is therefore up to the veterinarian to decide whether or not to provide a copy of patient history records to clients.
The issue of ownership of client records was challenged legally through the civil court system, to the Supreme Court and finally the Court of Appeal. On each occasion the plaintiff/appellant [the client] said he deserved to have a copy of the records because he had requested them.
Heard by Judges Jerrard, Holmes and Philippodes the Supreme Court of Brisbane handed down its findings in Maquire v Lynch [2007}QCA 290 on 7th September 2007. The Appeal was denied with the court finding the client had NO legal right of access to the veterinary records. Quoting from the judgement comments of Judge Holmes….The application is reminiscent of that in Breen v Williams  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 she had no such right. The doctor’s notes were his property compiled for his own information in treating and advising the patient. The appellant had no proprietary right or interest entitling her to access to them. The agreement between them was to treat the patient with reasonable skill and care; it might have required the provision of information to the appellant but that did not entitle her to access to, and the opportunity to copy, the doctor’s records. The fiduciary relationship between doctor and patient did not carry with it a right of access to records compiled by the doctor.
Providing patient history records to another veterinarian
If formally requested by a client, veterinarians must provide a copy of the patient history 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 pet. The receiving practitioner has no right to give a copy of those records to the client.
If the records are provided in a hard copy format (including radiography films) these must be returned to the original veterinarian within a reasonable timeframe.
Patient history records and premises closures
In the event of a 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 pets; or
- provided directly to clients.
A veterinarian cannot defend himself/herself against any action if an independent assessment of a radiograph is that no diagnosis can be made from it.
Old and inadequate equipment should be replaced; developing solutions should be maintained at the required levels and replaced according to manufacturer’s instructions. The film should be identified at the time of exposure and include the name of the practitioner or practice, client and animal, the date, and should clearly indicate the left and right sides of the animal. Stick-on labels attached after developing are unacceptable.
All equipment must be registered with Radiation Health.
Information should be kept in a form that can be demonstrated as being made at the time the procedure was performed and can be authenticated e.g. a hard copy in a bound volume. A computer record does not meet this requirement.
The minimum requirement is a surgical log showing the name of the procedure, when done, how done and what was used.
Anaesthetic logs should detail pre-anaesthetic examination, types of drugs and amounts used (pre-med, induction and post), method of administration and duration.
Every practice should have a method to maintain a ‘register’ of anaesthetic procedures.
The general consensus is for practitioners to favour a handwritten register of anaesthetic procedures as they occur and to have this as a separate record to the patient’s general record. This could be a sheet that records details of anaesthetic procedures in a chronological order with single line entries for each anaesthetic, or the anaesthetic procedure could be described in more detail on an animal anaesthetic form which is kept in a anaesthetic register file.
All possible options should be taken to locate the owner of uncollected animals (telephone, visit to last known address, enquiries of neighbours, friends, relatives). If contacted, instructions should be gained, in writing if possible, for future of animal, e.g. collection by owner, adoption, transfer to local government refuge, euthanasia.
If the owner cannot be located and the veterinarian is confident the owner is not going to collect the animal, a certified letter should be forwarded to the last known address of the owner advising that if the animal is not collected by a specified date, the animal will be disposed of.
After the specified date, veterinarians should endeavour to have the animal adopted out either privately or through the local refuge but avoid having it euthanased unless it is in the animal’s best welfare due to suffering.
This type of situation could be avoided by the practice insisting that clients sign an appropriately worded ‘admission form’ prescribing the rights of the parties in the event of non-collection and entitling the practitioner to dispose of the animal in a certain time after non-collection.
The overriding principle is that a veterinarian should always act in a professional manner and should do what is thought is morally correct in all cases.
Commercial boarding of animals
Where practices are boarding animals as distinct from hospitalising animals the Board’s policy is that there should be two separate and distinct accommodation areas. It must be perceived that the boarding area is an entirely different facility.
The Board acknowledges the stressful circumstances in which practitioners are placed when unexpected deaths occur in practice where it is difficult to tactfully and discretely recommend that a post-mortem examination be conducted.
The offer of a post-mortem should however always be given when there has been an unexplained death. In cases where the offer is initially refused and the veterinarian considers a dispute could arise, it is to the veterinarian’s benefit to press the point to the client that a post-mortem examination by an independent veterinarian employed at another practice or by a specialised pathology service should be undertaken to establish the cause of death.
In the interests of defusing any potential dispute arising from the death, an offer could be made to arrange an independent examination at either the owner’s expense or at the expense of the treating practice. At the least an in-house examination at no cost to the client should be offered.
Specialist referral procedure
A formal communication should be made by a referring veterinarian to a specialist providing information on the case. This is a critical component for the effectiveness of the veterinary referral process.
Specialists may not recognise cases as referrals without formal notification from the referring veterinarian.
The wishes of the referring veterinarian and the owner should be specified in the referral material.
The referring veterinarian should be provided with a detailed report on the outcome of the referral and if appropriate, the client should be advised to contact the referring veterinarian regarding continuing care of the patient.