Minimum Standards for Medical Records

PURPOSE: This rule describes the minimum standards for medical records. (1) Every veterinarian performing any act requiring a license pursuant to the provisions of section 340.200(28), RSMo, upon any animal or group of animals shall prepare a legible, written, individual (or group) animal and client record concerning the animal(s) which contains the requirements listed here. The medical record will provide documentation that an adequate physical examination was performed. (A) Name, address, and telephone number of animal’s owner or agent. (B) Name or identity, or both, of the animal(s), including age, sex, breed, weight, and color, where appropriate. (C) A brief history. (D) Notations of the physical examination. (E) Treatments or intended treatment plans, or both, including medications, amounts administered, dispensed or prescribed, and frequency of use. (F) A diagnosis or tentative diagnosis. (G) When pertinent, a prognosis. (H) Progress notes and disposition of the case. (I) Dates (beginning and ending) of custody of the animal with daily notations. (J) In the case of vaccination clinics, a certificate including the information required by subsections (1)(A) and (B) may serve as the medical record. (K) The veterinarian who created the record. (L) Name of the veterinarian who orders any radiographs. (2) Record and Radiograph Storage. All records shall be maintained for a minimum of five (5) years after the last visit, and all radiographs shall be maintained for a minimum of five (5) years from the date the radiograph was taken. Copies of records will be made available within a reasonable period of time upon the request of another treating veterinarian who has the authorization of the owner of the animal to which it pertains or directly to the owner or owner’s agent. Reasonable period of time means no more than five (5) business days or sooner in accordance with the patient’s medical condition. Documented proof of transfers of radiographs will be verifiable. (3) Computer Records. Computer records are acceptable medical records so long as the security of the computer is maintained. If computer records are used by a veterinarian, a daily and cumulative monthly back-up shall be made. The board strongly recommends that the information required in section (1) of this rule be maintained on hard copy. AUTHORITY: sections 340.210, 340.264, and 340.284, RSMo 2016.* This rule originally filed as 4 CSR 270-4.041. Original rule filed Nov. 4, 1992, effective July 8, 1993. Amended: Filed Dec. 1, 2005, effective June 30, 2006. Moved to 20 CSR 2270-4.041, effective Aug. 28, 2006. Amended: Filed March 31, 2008, effective Sept. 30, 2008. Amended: Filed July 25, 2018, effective Jan. 30, 2019. Amended: Filed Jan. 23, 2024, effective July 30, 2024. *Original authority: 340.210, RSMo 1992, amended 1993, 1995, 1999; 340.264, RSMo 1992, amended 1999; and 340.284, RSMo 1992.