Rule 4741-1-21. Recordkeeping

119.03 (A) A veterinarian performing a physical examination, diagnosis, treatment or surgery on an animal or group of animals shall prepare a written record or computer record concerning the animals containing, at a minimum, the following information: (1) Name, address, and telephone number of owner; (2) Identity of the animal, herd, or flock; (3) Except for herds or flocks, the age, sex, color, and breed; (4) Dates of examination, treatment and surgery; (5) Brief history of the condition of each animal, litter, herd, or flock; (6) Examination findings; (7) Laboratory and radiographic tests performed and reports; (8) Differential diagnosis; (9) Procedures performed/treatment given and results; (10) Drugs (and their dosages and routes of administration) administered, dispensed, or prescribed; (11) Surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agent used, the route of administration and the dosage; and (12) Anesthesia monitoring performed during surgical procedures. (B) Individual records must be maintained on each patient, except that records on livestock or litters of animals may be maintained on a per-client basis. (C) Medical records and radiographs are the physical property of the hospital or the proprietor of the practice that prepared them. Records, including radiographs, must be mintained for a minimum of three years after the last visit. (D) Medical records shall be released upon request from a treating veterinarian with a legitimate interest, and shall be returned to the originating practice within a reasonable time if requested. Copies of records must be made available upon request from the owner of an animal at a reasonable cost to the owner and within a reasonable time. A veterinarian may not withhold the release of veterinary medical records for nonpayment of a professional fee. (E) All regulated substances shall be recorded as required by federal and/or state regulations Last updated April 14, 2022 at 8:55 AM Supplemental Information Authorized By: 4741.03 (C)(9) Amplifies: 4741.22 (A)(25) 3/16/2027