Maintenance of Medical Records

 

DEPARTMENT OF BUSINESS AND PROFESSIONAL REGULATION
Board of Veterinary Medicine

RULE NO.: RULE TITLE:
61G18-18.002: Maintenance of Medical Records

NOTICE OF CHANGE

Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 38 No. 26, June 29, 2012 issue of the Florida Administrative Register.

The changes are as follows:

(1) through (2) No change.

(3) Medical records shall be created as treatment is provided or within 24 hours from the time of treatment contemporaneously written 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) through (9) No change.

 

THE PERSON TO BE CONTACTED REGARDING THIS NOTICE IS: Juanita Chastain, Executive Director, Board of Veterinary Medicine, Department of Business and Professional Regulation, 1940 North Monroe Street, Tallahassee, Florida 32399-0750.