4741-1-21. Recordkeeping

(A) A veterinarian performing a physical examination, diagnosis, treatment or surgery on an animal or group of animals shall prepare a written record or computer record concerning the animals containing, at a minimum, the following information:

(1) Name, address, and telephone number of owner;

(2) Identity of the animal, herd, or flock;

(3) Except for herds or flocks, the age, sex, color, and breed;

(4) Dates of examination, treatment and surgery;

(5) Brief history of the condition of each animal, litter, herd, or flock;

(6) Examination findings;

(7) Laboratory and radiographic tests performed and reports;

(8) Differential diagnosis;

(9) Procedures performed/treatment given and results;

(10) Drugs (and their dosages) administered, dispensed, or prescribed;

(11) Surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agent used, the route of administration and the dosage; and

(12) Anesthesia monitoring performed during surgical procedures.

(B) Individual records must be maintained on each patient, except that records on livestock or litters of animals may be maintained on a per-client basis.

(C) Medical records and radiographs are the physical property of the hospital or the proprietor of the practice that prepared them. Records, including radiographs, must be mintained for a minimum of three years after the last visit.

(D) Medical records shall be released upon request from a treating veterinarian with a legitimate interest, and shall be returned to the originating practice within a reasonable time if requested. Copies of records must be made available upon request from the owner of an animal at a reasonable cost to the owner and within a reasonable time. A veterinarian may not withhold the release of veterinary medical records for nonpayment of a professional fee.

(E) All regulated substances shall be recorded as required by federal and/or state regulations

Replaces: 4741-1-21

Effective: 9/1/2017
Five Year Review (FYR) Dates: 02/06/2022
Promulgated Under: 119.03
Statutory Authority: 4741.03(C)(9)
Rule Amplifies: 4741.22(A)(25)
Prior Effective Dates: 01/22/2003, 11/15/2007, 10/15/2012, 07/15/2014