Recordkeeping

(1) The following minimum standards apply to all patient recordkeeping. (a) Records shall be maintained for a minimum of three (3) years. (b) A separate log shall be maintained for all controlled substances. (c) Each patient record shall indicate the strength and quantity of any medication pre- scribed, administered or dispensed. In the case of companion animals, this record shall be maintained for each individual animal. (d) Records shall reflect the problems the patient presents and the veterinary interventions performed or prescribed. (e) Records shall reflect referral of cases where further expertise or equipment is needed. (f) A veterinarian shall comply with requests for veterinary records as required by the Med- ical Records provisions of T.C.A. § 63-2-101 et seq. (2) Medical records for small animal practices shall be clear, legible, retrievable, and contain per- tinent information such as: (a) Name, address, and phone number of the owner/agent. (b) Identification of patient including name, species, breed, age, sex, and description. (c) Separate record for each patient. This record may be in a group of records for the owner/agent. (d) Patient’s vaccinations, medical and surgical history and procedures. (3) Medical records for large animal practices shall be clear, legible, retrievable, maintained on ei- ther a herd, flock or individual basis, and contain: (a) Name, business/farm name, address, and phone number of the owner/agent. (b) Identification of any animal(s) suspected of having a reportable disease or other dis- ease with public health implications. (c) Relevant medical and surgical procedures, including vaccinations given and lab reports, to the individual, group, or herd. GENERAL RULES GOVERNING VETERINARIANS CHAPTER 1730-01 (d) A record of all drugs administered or dispensed, including quantity and withdrawal times. (4) Veterinarians providing written or oral instructions for persons who are not licensed as veteri- narians to perform accepted livestock management practices must record the order, including specific information on the substance of the order and the date given, in the records of the an- imal. (5) For the purpose of these rules, the records shall be “owned” by the practice. (6) Radiographs are considered to be a part of the client’s records. (7) Outside of a valid veterinarian-client-patient relationship, records from another veterinary practice may not be used as the sole basis for prescribing or dispensing medication.