This guideline outlines the appropriate standard expected of a registered veterinary practitioner in the course of veterinary practice. It should be read in conjunction with other related guidelines.

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Context to Guideline 7: Veterinary medical records

Veterinary medical records provide:

1. documentary evidence of the assessment, care, diagnosis, illness, and treatments or management plans provided to for an animal over time, and the communications relating to the provision of these veterinary services
2. a means of sharing an animal clinical history between professional peers and the veterinary team within a veterinary facility or workplace
3. a source of information for other veterinary practitioners who may care for or treat the animal
4. a record of the scheduled drugs used or supplied for the treatment of an animal and the reason for the use or supply
5. a basis for review and evaluation of the veterinary services delivered to the animal
6. a record of events in any legal proceedings and/or investigation into professional conduct or fitness to practise conducted by the Board.

Veterinary medical records must satisfy all relevant legislative requirements for their content, retention and disclosure. For example, the use, supply and administration of scheduled medications must be recorded in accordance with requirements of the Drugs, Poisons and Controlled Substance Act 1981.

The guidance presented here applies whether the veterinary service occurs in the clinic, an ambulatory service or remotely through methods such as telemedicine consultation.

A veterinary practitioner should arrange transfer of veterinary medical records to another veterinary practitioner in the event that the veterinary practice owning the veterinary medical records closes or the owner requests transfer to another veterinary practitioner.

A veterinary medical record is the property of a veterinary practice or veterinary practitioner who has created or contributed to it. A veterinary practitioner is not legally required to provide copies of their veterinary medical records for an animal to its owner if there is a reasonable justification not to do so. The refusal by a veterinary practitioner to provide an owner with an animal's veterinary record is not sufficient grounds on its own for the Board to investigate an allegation of professional conduct.

If formally requested by an owner, a veterinary practitioner should provide a copy of the veterinary medical record to another veterinary practitioner if the owner is seeking a second option or if the owner wishes to nominate another veterinary practitioner to take over the ongoing care of their animal. The receiving veterinary practitioner should obtain consent from the original veterinary practitioner before providing them to an owner.

A veterinary medical record should be prepared for wildlife and stray animals and should identify, as best as possible, the animal, and the procedure, treatment or veterinary service provided to the animal. For wildlife, the record should include the location where the animal was found.

Board Guideline 7 clearly sets out what needs to be included in a veterinary medical record. A good example of a medical record is one that can be picked up, read and understood by another veterinary practitioner, allowing them to provide continuity of care. This includes any specific context that may influence ongoing care of the animal.

To ensure efficiency and accuracy, a veterinary practitioner should create veterinary medical records as close as possible to the time they provided veterinary services, while events are fresh in their mind. Veterinary practitioners and practices should allow sufficient time during the working day to ensure medical records are able to be completed accurately and kept up to date in a timely manner. 

More information: VRBPV Guideline 7 (on this page) details the information that should be included in a veterinary medical record.

For efficiency and consistency, veterinary practitioners commonly use clinical record templates that support logical information gathering and analysis, communications, decisions, actions and outcomes. Such templates include standard consultation, consent, hospitalisation, prescription, anaesthetic and surgeon record templates (hard copy or within software), and communication templates (e.g., owner updates, relevant information and aftercare).

Care should be taken when using templates to remove default entries, ensuring that records accurately reflect all that was said and done during the examination. Commonly understood shorthand is generally accepted (e.g. NAD, WNL, HBC, DOA, CRT, RR HR), if it can be readily understood by the veterinary team and veterinary practitioners to whom an animal is referred.

To ensure efficiency and accuracy, a veterinary practitioner should create veterinary medical records as close as possible to the time they provided veterinary services, while events are fresh in their mind. Veterinary medical records can be entered by someone other than the vet, such as a veterinary nurse or via transcription technology. If this occurs, it is the veterinary practitioner's responsibility to ensure accurate recording and attribution of their work.

During clinical examination of an animal, observations and measurements may fall within an expected normal range for the type of animal (species, breed, age etc.). It is good to record all findings even if they are believed to be normal for the animal being examined, as this reflects the scope of a veterinary practitioner's examination and is a reference for ongoing or future care.

Commonly used abbreviations such as WNL (within normal) or NAD (no abnormalities detected) may be acceptable to include in the medical record. In some situations, a specific measurement may be more appropriate, e.g., when monitoring a parameter of particular interest.

If a template covering standard examination points is used, the record should accurately reflect anything that was "Not Examined". the Board would generally interpret a blank field or record that is silent on a particular point as indicating that it had not been examined or not occurred.

If a veterinary practitioner does not examine something which they consider to be reasonably expected to be examined, the reason for non-examination should be recorded at that time.

Yes, veterinary practitioners should document conversations with an animal’s owner or their designated representative in the animal’s veterinary medical record. Where possible, a record of these conversations should be documented at the time of the conversation. This is to ensure that the veterinary practitioner is able to provide an accurate representation of the conversation if it is needed in the future. It is important to note that the Board considers the act of altering historical records in response to a complaint to be unprofessional conduct. When considering material presented with a complaint, the Board will take into account whether the relevant records are congruent with the regular standard of a veterinary practitioner's records.

The following details of conversations should be included in the veterinary medical record:

• discussion of treatment and/or management options for the animal, including the limitations, risks and costs of those options (Guideline 7.4). Re risk, discussion of the risks associated with each recommended option needs to be included (Guideline 7.1).
• the treatment option(s) chosen by the owner during discussions, including why they made that choice (Guideline 7.4)
• the owner’s verbal consent to treatment and financial consent to the costs of treatment, if they provided their consent verbally (Guidelines 4.7 and 4.8)
• updates on treatment costs discussed with the owner (Guideline 4.9)
• discussion of ongoing care and future management plans (Guideline 7.4)
• any discussion of financial constraints affecting the owner’s decisions about their animal's treatment/management (Guideline 7.4).
• if the veterinary practitioner works in a practice that advertises specialist veterinary services, but is not a Board-registered veterinary specialist, discussion of any limitations to the veterinary services they provide (Guideline 17.6)
• if the veterinary practitioner chooses not to treat the animal, communication of this with alternative service options (Context, Guideline 3)

Yes, veterinary practitioners need to have a veterinary medical record for stray animals and wildlife. The record should identify the animal, and the procedure, treatment or veterinary service provided to the animal as accurately as possible. For wildlife, the record should include the location where the animal was found (Context, Guideline 7).

As property rights do not apply to wildlife, in medical records the owner can be recorded as the person who presented the animal for veterinary services (Context, Guideline 1). Required details of discussions with that person should be recorded in the animal’s veterinary medical record.

If the person who presented the animal is not authorised to keep wildlife under the Wildlife Act 1974, the veterinary practitioner cannot give the animal back to that person. The wildlife must be given to an authorised wildlife shelter operator or wildlife carer. The veterinary practitioner should discuss ongoing care and future management plans with the shelter operator or carer, and the details of this discussion should also be noted in the veterinary medical record.

More information: Veterinary care for wildlife (download detailed factsheet from this page), Department of Environment, Land, Water and Planning.

The Board's Guidelines specifically require a veterinary practitioner to:

• keep true and accurate records of all veterinary medications administered or supplied and retain those records for at least 7 years (Guideline 14.1).
• retain sufficient evidence of the veterinary practitioner-owner-animal (VOA) relationship to demonstrate compliance with all legal requirements and professional obligations (Guideline 13.2).

This requirement applies not only to the medical history itself, but also to other medical records including anaesthetic monitoring charts, hospital charts and consent forms.

Veterinary medical records must satisfy all relevant legislative requirements for their content, retention and disclosure (Context, Guideline 7). Retention periods for various records may be referred to in regulations such as the Drugs, Poisons and Controlled Substances Regulations 2017, Agricultural and Veterinary Chemicals (Control of Use) Regulations 2017, Prevention of Cruelty to Animals Regulations 2019, and Domestic Animals Regulations 2015. Other relevant laws that may refer to retention periods include business, taxation and privacy laws. For more information on retention requirements, veterinary practitioners can consult their indemnity insurer or legal practitioner.

Veterinary medical records are either owned by a practice or an individual medical practitioner (as per general principles in case law listed below). They are not owned by the animal owner. However, the consent of the owner is required for the transfer of the records to another veterinary practice or practitioner.  It would be sensible for the referring veterinary practitioner to obtain the owner's consent to transferring records at the time the referral is made, and then promptly transfer those records to the other practice.

When it comes to sharing copies of medical records with an animal's owner, a copy of the records or a summary of the information contained in them should be provided to the animal owner on request. Alternatively the veterinary practitioner should effectively communicate the reason for not providing the records (Guideline 7.8). Good communication about requests for medical records is important. An open dialogue with the animal’s owner can help clarify why they want the medical records, so concerns may be addressed. This can be a good opportunity to build rapport. 

The Board’s expectations about the sharing of veterinary medical information in a referral situation is set out in Board Guideline 12 – Referrals between veterinary practitioners, which states:

Where an animal is referred to one or more other veterinary practitioners, open collaboration and clear communication between all parties will achieve the best outcome for the animal. A referral by a veterinary practitioner to another veterinary practitioner should provide sufficient information to describe the issue of concern and give a comprehensive history of the clinical management, diagnostics and/or treatment undertaken to date.

Overall, a veterinary practitioner should prioritise the welfare and ongoing continuity of care of the animal when deciding whether to provide full records. 

A veterinary practitioner taking on a new patient or receiving a referral could potentially adopt proactive steps or alternative business practices to minimise the risk of not having the information needed during a consultation. For example, veterinary practitioners may consider asking the owner to provide a copy of the records at the time of making an appointment or within a certain number of days before the consultation. A veterinary practitioner may also consider not accepting or making appointments until they have received the relevant medical records (from either the owner or referring veterinary practitioner).

Case law on ownership of records

• Breen v Williams ("Medical Records Access case") [1996] HCA 57; (1996) 186 CLR 71 (6 September 1996)
• Health Services for Men Pty Ltd & v D'Souza & Ors [2000] NSWCA 56 (22 March 2000)
• Mid-City Skin Cancer and Laser Centre v Zahedi-Anarak [2006] NSWSC 844 (13 September 2006)

The Board’s expectations about the sharing of veterinary medical information in a referral situation are set out in Board Guideline 12 – Referrals between veterinary practitioners, which states:

Where an animal is referred to one or more other veterinary practitioners, open collaboration and clear communication between all parties will achieve the best outcome for the animal. A referral by a veterinary practitioner to another veterinary practitioner should provide sufficient information to describe the issue of concern and give a comprehensive history of the clinical management, diagnostics and/or treatment undertaken to date'.>

A veterinary practitioner could potentially adopt proactive steps or alternative business practices to minimise the risk of not having the information needed during a consultation. For example, veterinary practitioners may consider asking the owner to provide a copy of the records at the time of making an appointment or within a certain number of days before the consultation. A veterinary practitioner may also consider not accepting or making appointments until they have received the relevant medical records (from either the owner or referring veterinary practitioner).

Veterinary practitioners may be required to give access to veterinary medical records to authorised parties under various laws. If unsure whether a request for records is legitimate, a veterinary practitioner should ask the requesting person for the specific section of the law under which the request is being made and proof that they are an authorised person under that law, e.g. their authorisation identity card. A veterinary practitioner may also wish to consult their indemnity insurer or legal practitioner if they receive such a request.

A non-exhaustive list of persons authorised to have access to veterinary medical records are:

• an authorised inspector under the Prevention of Cruelty to Animals Act 1986, e.g., an RSPCA inspector or local council officer
• an authorised inspector under the Drugs, Poisons and Controlled Substances Act 1981, from the Medicines and Poisons Regulation Branch of the Victorian Department of Health
• an authorised inspector under the Agricultural and Veterinary Chemicals (Control of Use) Act 1992, e.g., from Statewide Specialist Chemicals, Agriculture Victoria, Department of Jobs, Precincts and Regions
• a Board member appointed under section 63 of the Veterinary Practice Act 1997 (or a person to whom the Board has delegated its functions), 
• an authorised inspector under the Racing Act 1958
• an authorised inspector under legislation administered by the Australian Pesticides and Veterinary Medicines Authority
• the police under various laws.

While veterinary practitioners do not have to provide veterinary medical records to pet insurance companies, they usually comply with such requests. If a veterinary practitioner is asked for a large amount of information that may be unrelated to a pet insurance claim, they can ask the pet insurance company for more information about the request. Veterinary practitioners may also consult the Australian Veterinary Association (Pet insurance) or their indemnity insurer or legal practitioner about requests for information from pet insurance companies.

If an animal owner’s pet insurance claim is rejected by a pet insurance company on the grounds that a veterinary practitioner has not supplied the veterinary medical record , the owner may:

• ask for the matter to be escalated to a complaint handling team within the pet insurance company
• If the matter is unable to be resolved with the pet insurance company, lodge a complaint with the Australian Financial Complaints Authority.

One of the reasons medical records are created and maintained is that they are a source of information for other veterinary practitioners who may care for or treat an animal (Context, Guideline 7).

The general expectation of the Board in relation to sharing medical records is that a veterinary practitioner provides copies of an animal’s veterinary medical records or a summarised clinical history to the owner or their designated representative on request (Guideline 7.8). 

An alternative may be for the veterinary medical record to be shared directly with another veterinary practitioner. If formally requested by an owner, a veterinary practitioner should provide a copy of the record to another veterinary practitioner if the owner is seeking a second option or if the owner wishes to nominate another veterinary practitioner to take over the ongoing care of their animal. The receiving veterinary practitioner should obtain consent from the original veterinary practitioner before sharing the record with the owner (Context, Guideline 7).

While the Board’s general expectation is that records should be shared, a veterinary medical record is the property of a veterinary practice/practitioner who has created or contributed to it. A veterinary practitioner is not legally required to provide copies of their veterinary medical records to an animal’s owner if there is a reasonable justification not to do so (Context, Guideline 7). More information: see FAQ above, 'Who owns a veterinary medical record: the veterinary practitioner or the owner?'

Yes. The Board's expectation is that, if formally requested by an owner, a veterinary practitioner should provide a copy of the veterinary medical record to another veterinary practitioner if the owner is seeking a second option or nominates another vet to take over the ongoing care of their animal. The receiving veterinary practitioner should obtain consent from the original veterinary practitioner before providing the transferred record to the owner (Context, Guideline 7).

However, while the Board’s general expectation is that records should be shared, a veterinary practitioner is not legally required to share copies of veterinary medical records because they are the property of the veterinary practice or veterinary practitioner who created or contributed to them (Context, Guideline 7). More information: see FAQ above, 'Who owns a veterinary medical record: the veterinary practitioner or the owner?'

Does a veterinary practitioner need an animal owner's consent to provide medical records to another veterinary practice? What should a veterinary practitioner/veterinary business do with veterinary medical records if their practice is closing down?

This material is current only at the time of publication and may be changed from time to time. The Board reviews and updates the Guidelines on a continuous basis to reflect changes in the science and knowledge base underpinning contemporary veterinary practice. The Board will take reasonable steps to inform the veterinary profession when such updates are released but it remains the responsibility of the individual veterinary practitioner to ensure that their knowledge and application of these Guidelines to their own practice is current.

While the Board has made every effort to ensure that the material in these Guidelines is correct in law, it shall not be liable to any veterinary practitioner or any other person or entity in relation to any claim, action or proceeding whatsoever (whether in contract, negligence or other tort or in proceedings seeking any other form of legal or equitable remedy or relief) for any inadequacy, error or mistake, or for any deficiency in the whole or any part of this document (including any updates incorporated in the document from time to time). A veterinary practitioner or any other person or entity acting upon the contents of this document acknowledges and accepts that this is the basis upon which the Board has produced these Guidelines and made them available to such person or entity.