Veterinary medical records guidance
Make records at or close to the time of events
The Board’s Guideline 7 on veterinary medical records requires, ‘7.2: A veterinary practitioner takes reasonable steps to ensure their entries to a veterinary medical record are completed at the time they provide veterinary services’.
Making clear and accurate veterinary medical records at the time of events, or as soon as possible afterwards, is essential for the continuing good care of an animal and keeping the public safe.
As accounts of events may differ, medical records often provide the foundation for reconciling the two. Therefore, the absence of contemporaneous medical records can significantly impact the ability to determine the facts of a complaint.
In a recent investigation, it was discovered that the veterinary practitioner had amended the record after becoming aware of a complaint (and several months after the events taking place). Poor records management did not support the practitioner’s submission that they had undertaken specific assessments or provided relevant information to the complainant. As the information had been added much later than the events, it could not be established whether the detail in the amendments actually occurred.
The Board generally will review written information shared with the complainant or veterinary peers at the time of, or close to, the relevant events.
The Board understands that there may be occasions where medical records are unable to be reasonably completed in time or you later recall information to include in the records. In these circumstances, we recommend that you write changes or additions underneath the original record, along with the date of the addition.
Your memory of consultation and treatment is always going to be freshest on the day, so making records at the time of, or close to, events will help to ensure your records are accurate and include all necessary information.
It is in your best interests to ensure you document all relevant details relating to clinical management, including diagnostic options and communications with the owner, at or close to the time of events.
Sharing medical records
The Board receives complaints from animal owners, and sometimes other vets, about not being able to get copies of medical records and test results from a veterinary practitioner.
The Board’s position is that, as records are owned by the veterinary practitioner or practice, the Board cannot compel records to be provided.
However, the Board’s first principle of professional conduct is, ‘The wellbeing of an animal is central in a veterinary practitioner’s decision-making in the provision of veterinary services’. Therefore, you should consider whether sharing information about a patient is necessary to facilitate continuity of care for the animal.
If you choose not to share records where the patient’s wellbeing may be compromised, consider sharing a summary of consultations, test results and your clinical management plan and actions. If you decide not to do either, you should provide reasons for this to the animal’s owner or the requesting veterinary practitioner (Guideline 7.8).
Relevant guidelines
Links to guidance on using AI to make records