Professional Practice Standard
Published: December 2014
Revised: November 2015
Introduction
The complete medical record is a compilation of all information that pertains to the care of an animal or a group of animals, and documents the management of a case. 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. The medical record is also a communication tool which facilitates the continuity of care for animals both within and between veterinary medical-care teams.
A quality record is fundamental to quality practice, and this Professional Practice Standard itemizes the essential elements of a quality record. As such, justification for any departure from this Professional Practice Standard should be documented in an appropriate place within the medical record.
The Professional Practice Standard: Medical Records applies to all veterinarians and all record systems (e.g., electronic, paper or combination of both). Information requirements for specific species is found in Ontario Regulation 1093.
Practice Expectations
A veterinarian meets the Professional Practice Standard: Medical Records when they:
Create a record for each animal(s) or group of animals where a veterinarian-client-patient relationship (VCPR) is established.
Ensure records are accessible.
Ensure the record provides an accurate, complete, and up-to-date profile of the animal(s) or group of animals to enable continuity of care. Ensures that each time a record is updated, the update or change to the record is dated and documented in a clearly identifiable manner and the content of the record before each change or update is preserved.
Maintain electronic records in accordance with the electronic records requirements outlined in O. Reg. 1093 Section 22. (6).
Ensure that, in situations where a change to the medical record is required, an audit trail is established where the original content is preserved, and a record of the author and date/time is established. Changes to the original content must be approved by the veterinarian.
Establish procedures and protocols to protect client confidentiality and safeguard records against loss, damage, unauthorized access or disclosure.
Respond to or make requests for, and/or provides relevant historical (i.e. medical) information in a timely manner that facilitates the continuity of care of an animal(s) or group of animals between and among veterinarians.
Respond within two (2) business days to requests from clients or another veterinarian to transfer complete records.
Maintain records for five (5) years after the last entry is made.
Destroy records in a manner that protects client confidentiality.
Guide to the Professional Practice Standard
A separate Guide to the Professional Practice Standard: Medical Records has been developed by the College and can be found on the College’s website at www.cvo.org.
Legislative Authority
R.R.O. 1990, Reg. 1093: General, s. 22-28 (Veterinarians Act)
Resources
The following can be found at the College’s website at cvo.org:
Guide to the Professional Practice Standard: Medical Records
Professional Practice Standard: Informed Client Consent
Guide to the Professional Practice Standard: Informed Client Consent
Professional Practice Standard: Establishing, Maintaining, and Discontinuing a Veterinarian-Client-Patient Relationship (VCPR)
Guide to the Professional Practice Standard: Establishing, Maintaining, and Discontinuing a Veterinarian-Client-Patient Relationship (VCPR)
A variety of additional resources (i.e., samples, forms) can also be found on the College’s website.
College publications contain practice parameters and standards which should be considered by all Ontario veterinarians in the care of their patients and in the practice of the profession. College publications are developed in consultation with the profession and describe current professional expectations. It is important to note that these College publications may be used by the College or other bodies in determining whether appropriate standards of practice and professional responsibilities have been maintained. The College encourages you to refer to the website (www.cvo.org) to ensure you are referring to the most recent version of any document.