Content of practice records

Regulation 24.

  1. A veterinarian must, for each animal treated by the veterinarian, keep a record including:
    1. the animal’s identifying details; and
    2. the following information for each consultation about the animal
      1. details of any condition or injury of the animal;
      2. any provisional or definitive diagnosis;
      3. full details, including the date, of any examination, procedure or test performed;
      4. full details of any treatment given, including details of any drugs administered or dispensed;
      5. results of any treatment given;
      6. details of any instructions given when the animal is discharged.
  2. The veterinarian must keep the record for three (3) years from the day the last information about the animal is included in the record.

    As an extension of the Regulation the Board has nominated the components of model clinical records as:
  • Identity of the veterinarian creating the record
  • Date of record
  • Patient and client ID
  • Presenting clinical signs
  • Record of examinations including history, vital signs and weight
  • Provisional diagnosis and rule outs
  • Treatment plan
  • Diagnostic examination results
  • Chronological list of treatments
  • Hospital admission form and/or general anaesthetic consent form
  • Surgery/anaesthetic log
  • Referral detail and reports
  • Discharge instructions
  • Client communication record
  • Billing record