61G18-18.002. Maintenance of Medical Records

(1) There must be an individual medical record maintained on every patient examined or administered to by the veterinarian, except as provided in (2) below, for a period of not less than three years after date of last entry. The medical record shall contain all clinical information pertaining to the patient with sufficient information to justify the diagnosis or determination of health status and warrant any treatment recommended or administered.

(2) When a veterinarian is providing services to a client owning or leasing 10 or more animals of the same species at a location where the client keeps the animals, one medical record may be kept for the group of animals. This record must include the species and breed of the animals, and the approximate number of the animals in the group. However when one specific animal is treated, the record must include the identification, diagnosis, and treatment regime of the individual animals examined and treated at each visit to the location, as well as all other information required by this rule.

(3) Medical records shall be created as treatment is provided or within 24 hours from the time of treatment and include the date of each service performed. They shall contain the following information:

Name of owner or agent

Patient identification

Record of any vaccinations administered

Complaint or reason for provision of services

History

Physical examination to include, but not limited to patient weight, temperature, pulse, and respiration, or noted exceptions to the collection of said information

Any present illness or injury noted

Provisional diagnosis or health status determination

(4) In addition, medical records shall contain the following information if these services are provided or occur during the examination or treatment of an animal or animals:

Clinical laboratory reports

Radiographs and their interpretation

Consultation

Treatment – medical, surgical

Hospitalization

Drugs prescribed, administered, or dispensed along with the route, strength, and dosage of the drug and time said drug was administered if not otherwise discernible from the record

Tissue examination report

Necropsy findings

(5) A veterinarian shall maintain confidentiality of all patient records in his/her possession or under his/her control. All patient records shall not be disclosed without the consent of the client. Appropriate disclosure may be made without such consent:

(a) in any civil or criminal action, unless otherwise prohibited by law, upon the issuance of a subpoena from a court of competent jurisdiction and proper notice by the party seeking such records to the client or his/her legal representative;

(b) when required by the Board's rules.

(6) A veterinarian shall, upon a written request, furnish, in a timely manner without delays for legal reviews, a true and correct copy of all of the patient records to the client, or to anyone designated by the client. Such records release shall not be conditioned upon payment of a fee for services rendered, except for the reasonable cost of duplication.

(7)(a) Reasonable costs of duplication of written or typed documents or reports shall not be more than $1.00 per page for the first 25 pages, and shall not be more than 25 cents per page for each page in excess of 25 pages.

(b) Reasonable costs of reproducing x-rays, and such other special kinds of records shall be the actual costs. The phrase “actual costs” means the cost of the material and supplies used to duplicate the record, as well as the labor costs and overhead costs associated with such duplication.

(8) It is understood that there may be several files in different locations. Sufficient cross indexes are to be maintained for prompt retrieval when required.

(9) Medical records may be maintained in an easily retrievable electronic data format; however, the licensee shall be responsible for providing an adequate backup system to assure data is not lost due to system failure.

Rulemaking Authority 474.206, 474.2165 FS. Law Implemented 474.2165 FS. History–New 4-6-81, Formerly 21X-18.02, Amended 3-13-90, Formerly 21X-18.002, Amended 7-4-95, 12-30-97, 8-23-98, 11-18-12.