Records

Good record keeping is imperative. Records should be completed at the time of the consultation, and include all relevant information.  Records can be handwritten, or recorded on the computer.   Whichever system is used, it is important that the record is completed at the time of the consultation.  If there is a clear need to make changes or additions to the handwritten records, the date of the change should be recorded and signed by the veterinarian.

A copy of the complete record will be required by the Board if a complaint is lodged.  Your records are the 'first line' of evidence, so it is in the vets interest to ensure your records are complete.   The standard used by the Board when assessing complaints is 'If it's not written down; it's not done'. 

Copies to owners

Clients may request a copy of the clinical records of their animal/s.  Copies should be provided in most circumstances without charge; though cost recovery of printing/photocopying is appropriate.   A copy of the clinical record may be with-held from the client if fees for services provided are outstanding.  X-rays are not required to be provided as part of the clinical record - they are deemed to be the property of the vet practice.

It is an expectation that full copies of records will be provided to another vet if the owner seeks another opinion.  X-rays should also be provided in this circumstance, but should be returned if requested.

Confidentiality and Disclosure of information

The Board has recently endorsed Guidelines on when it is appropriate to disclose information about clients and animals; and when it is not - download the Guideline on Client Confidentiality and Disclosure 9-07.pdf