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Information for Veterinary Professionals

As a licensed member, you will find helpful information in this section to assist you with making changes to your licence and managing the accreditation of a veterinary facility. You will also find information concerning professional conduct and quality practice. 

Medical Records and Transfer of Medical Information

Medical records provide the basis for the continuity of veterinary care. A complete medical record outlines the veterinary services provided to an animal or group of animals and ensures that care can be resumed seamlessly from one veterinarian to the next, from one visit to the next.  It is a legal document that represents the veterinarian’s thought process, decisions, judgment, actions, and interactions with others (clients, colleagues, other caregivers, and service providers such as specialists and laboratories), each of which has an impact on patient outcomes.

Frequently Asked Questions

Below are a few of the questions and answers that the College frequently receives about medical records and the transfer of medical information through its Practice Advisory Service.

Can a veterinary clinic maintain logs electronically?

Logs can be maintained in a paper based or electronic format (the clinic does not need to maintain both). Regardless of format, all requirements are to be recorded. With electronic logs (as with all electronic medical records), there must be the ability to print the logs if required.

How long does a veterinary clinic have to keep medical records?

Medical records are kept for a minimum of five years after the date of the last entry made.  Radiographs are considered to be part of a patient’s medical records and therefore, need to kept until the patient record can be removed from the clinic’s files (not based on the date the radiograph). Logs that contain information about a patient also need to be kept for as long as the patient’s records are active.

If a client declines to pay the fee to obtain a copy of their animal’s medical record, how can the veterinarian meet their obligation to provide the medical record to their colleague who is now treating the animal?

Veterinarians are allowed to charge a reasonable fee to recover the cost of making a copy of a patient’s medical record. Materials, staff time, and courier/postage fees are examples of these costs. How that fee is dealt with will be up to the parties involved. In a situation where the client or veterinarian has refused to pay for a complete copy of a record, a veterinarian is still obligated to provide relevant medical record information to a colleague. This information can be given verbally or as a written summary. The best interest of the patient and their continuity of care necessitate the timely and accurate transfer of medical information between colleagues. Patient information or a copy of the patient record should be transferred within two business days (or sooner) when a request for the information is made.

Is a veterinarian required to provide a client with a copy of their animal’s medical record?

Yes, veterinarians are required to provide either a copy or a summary of the medical record to a client upon request. The physical copy of the medical record is the property of the veterinary clinic but the information contained in the record belongs to the client and the client has the right to access the content of their animal’s medical record.  A veterinarian is allowed to recover reasonable costs for producing copies of medical records.

When ownership of an animal changes and the new owner requests medical records that were created at the time that the animal was owned by the previous owner, is consent from the previous owner required?

Yes, the medical record information belongs to the owner and the previous owner’s consent must be obtained before that information can be provided to the new owner.

Professional Practice Standards and College Policy

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