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Veterinary Medical Records FAQ
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What information has to be on veterinary medical records?

The major elements of medical records should include:

  • owner information
  • animal identification
  • chief complaint
  • physical exam
  • treatment
  • vaccination history
  • history
  • prognosis
  • diagnosis or tentative diagnosis
  • chronological order of medical and surgical events
  • various reports (laboratory, radiology, cardiology, etc.)
  • professional billing

How long do I have to keep veterinary records?

Veterinary patient records must be retained for three years since the date the animal was last seen. New York State law defines veterinary records as "all information concerning or related to the examination or treatment of the animal kept by the veterinarian in the course of his or her practice.”

The law requires veterinarians to provide animal owners with copies of treatment records upon written request of the client. Veterinarians are permitted to charge a reasonable fee for the copying of such records. Records must be provided within a reasonable time frame.

If the client requests X-rays, veterinarians are encouraged to transfer them to a referring veterinarian, if possible. It is strongly suggested that veterinarians retain original X-rays as part of the client record; however, a copy of the X-ray must be provided to the client at a reasonable cost to the client within a reasonable time period. Failure to provide records as outlined above is defined as unprofessional conduct.

Controlled substance records must be retained for five years since the date you last saw the animal.

A client is requesting his dog's medical records. He hasn't paid the bill. Do I have to provide copies of his pet's records?

Yes. You cannot withhold records of any client, including a client who owes you money. The law specifically requires veterinarians to provide animal owners with copies of treatment records upon written request of the client.  Veterinarians are permitted to charge a reasonable fee for the copying of such records. Records must be provided within a reasonable time period.  

Original medical records, including radiographs and laboratory results, are the property of the veterinary facility and should be retained unless subpoenaed by court order. You can offer to have a copy made of the X-ray if the client agrees to pay the cost.

The Education Law requires veterinarians to provide a copy of the patient records to clients who request them. However, I also understand that veterinarians are not included in "right of privacy” laws that apply to attorneys, for example. What’s the difference?

New York State law provides for the confidentiality of records for the following relationships: attorney/client; physician/patient; dentist/patient; chiropractor/patient; nurse/patient. There is no specific confidentiality privilege between a veterinarian and his/her client.  

However, the New York State Education Law’s Regents Rules defining unprofessional conduct state that professionals licensed under Title VIII (including veterinary medicine) may not "reveal personally identifiable facts, data or information obtained in a professional capacity without the prior consent of the patient or client, except as authorized or required by law”; i.e., subpoena. To do otherwise is considered unprofessional conduct and places the professional’s license in jeopardy.

I’m a board-certified specialist who was recently referred a case by a colleague. The owner of the dog has now filed a complaint with OPD against the referring veterinarian. OPD has contacted my office and asked for copies of my records on the dog. Can I give them the records? I’m nervous about being dragged into this situation. What should I do?

Because the owner filed against the referring veterinarian, not you, you must get permission from the client to share records with OPD. If you get the owner’s permission by telephone instead of in writing (either is permitted), have another staff member witness the approval on a telephone extension line. Be sure to document the consent in the patient record.
All veterinarians should be cautious when communicating with OPD. If the investigator wants to visit your office, schedule his/her visit when you are available to spend whatever time is necessary with them. Remember that anything you or one of your staff members say becomes part of the investigatory file and can be used as evidence against you. An OPD investigator evaluates all medical records he/she reviews, looks for general compliance with laws and regulations, and looks for general conformance with accepted standards of practice in the profession. 

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