2017 June - Ownership, writing, maintaining and releasing records
A veterinarian’s responsibilities in relation to veterinary and animal health records are covered in three clauses of the Veterinary practitioners code of professional conduct:
Provision of records
Under the Code (clause 9), a veterinary practitioner who has previously treated an animal must, when requested to do so, and with the consent of the person responsible for the care of the animal, provide copies or originals of all relevant case history records directly to another veterinary practitioner who has taken over the treatment of the animal.
Writing and maintaining records
Under the Code (clause 15):
- A veterinary practitioner must ensure that a detailed record of any consultation, procedure or treatment is made as soon as is practicable
- The record:
- Must be legible and in sufficient detail to enable another veterinary practitioner to continue the treatment of the animal, and
- Must include the results of any diagnostic tests, analysis and treatments
- If a record is altered, the alteration must be clearly identified in the record as such
- A veterinary practitioner must ensure that all records of any consultation, procedure or treatment are retained for at least 3 years after they are made.
Under the Code (clause 12) a veterinary practitioner must, except as otherwise required by the Code, maintain the confidentiality of information obtained in the course of his or her professional practice.
Ownership of records
With respect to the ownership of records the Board has previously commented on this issue in Boardtalk. The courts have determined that medical records are either owned by the practice or by the individual medical practitioner.,, Privacy legislation now makes it clear that a person has the right to access all personal information about him or her but animal health information is not covered by privacy legislation and these cases continue to provide general principles and guidance for questions of ownership of veterinary and animal health records.
Writing and maintaining records
The Board has commented on these issues previously in Boardtalk due to the importance of records when investigating a complaint. The Board is often confronted with two versions of what has happened and a contemporaneous written record will provide more reliable evidence than a written recount of events.
The current standard of record keeping has also increased over the years but the key element in the Code is for veterinarians to ensure that the details in the record are legible and in sufficient detail for another veterinarian to continue the treatment of the animal.
Records may be requested by the Board when investigating a complaint and also may be subpoenaed by the courts so it is important to ensure that they are accurate and objective.
It is vital that the practice ensures there are procedures in place to retain records for at least 3 years after they are made and all practices should therefore have computer records backed up as often as practicable. Tapes and portable drives should also be stored off site.
Release of records
In all cases consent should be obtained from the client before releasing records relating to that client. The Board also recommends that permission is sought from the individual veterinarian, superintendent, or owner of the veterinary practice depending on circumstances prior to releasing animal health records.
When a specialist or other veterinarian has visited the practice to treat an animal it is likely, based on the above, that the practice would be the owner of the records however it would be prudent and ethically appropriate to discuss this matter with the specialist or other veterinarian prior to any release.
Where the veterinary practitioner holds the records of another practitioner that have been provided pursuant to the Code (cl 9) the agreement of that practitioner should be sought prior to releasing the records.
When releasing records, veterinary practitioners must also be mindful of the privacy interests of third parties whose personal information may be included in clinical records. In addition to specialists and other veterinarians as above, another example is where the records for an animal include information obtained when the animal was owned or cared for by a different client. Whilst records may be held in one file for an individual animal with multiple clients over time, each client must provide consent for release of information pertaining to when that client was responsible for the care of the animal.
Before releasing records please also consider what other personal information these records hold. A person leaving or who has left a relationship may not wish their contact details to be inadvertently provided to the former partner.
Finally, the Code also provides that veterinary practitioners must at all times act with a primary concern for the welfare of animals. Even where there is no obligation to provide a copy of the clinical records to a third party, it may be appropriate for the veterinary practitioner to disclose, with consent from the client, information from the records that is necessary to facilitate the treatment and care of the animal.