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.
Context to Guideline 7: Veterinary medical records
Veterinary medical records provide:
- 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
- a means of sharing an animal clinical history between professional peers and the veterinary team within a veterinary facility or workplace
- a source of information for other veterinary practitioners who may care for or treat the animal
- a record of the scheduled drugs used or supplied for the treatment of an animal and the reason for the use or supply
- a basis for review and evaluation of the veterinary services delivered to the animal
- 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.
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.