Who determines the format of veterinary medical records

Veterinary medical records include forms, documents, and logs which record the treatment and care of animal patients. These are dynamic documents that record the sequence of events each time the veterinarian sees or communicates with that particular pet or client. The records are benchmarks and serve as detailed written descriptions of each patient's medical condition, its progress and its resolution or outcome. In addition to the above purpose, medical records also facilitate rapid retrieval of patient and client information. Records also provide written documentation of medical decisions and client consents for legal purposes. This is providing protection to the veterinarian and clinic staff. Records also provide valuable statistical information about the client or pet population and how the practice should be headed to meet all the needs and wishes of the public it serves. The patient record comprises the core of the veterinary patient medical records and is therefore simply referred to as "the medical record" or "the pet's file". It contains the pertinent facts about the patient's life and health history.

Information to be recorded includes:
1. Owner's information
A. Names (Include different last names)
B. Address
C. Phone number - more than one is better, and an emergency contact may be good too. Include cell phone number if have.
D. Client workplace info and phone numbers.
E. Client financial status and methods allowed for payments of services.

Knowing that many people live together these days without being married, it often is best
to ask if there is a "co-owner" in the family rather than a spouse. Established clients should have the accuracy of their addresses and telephone numbers
verified at each visit. Changes should be made immediately.

2. Animal's Information
A. Species
B. Breed & colour
C. Sex and Reproductive Status
D. Age
E. Name
F. Source of pet and reason for owning pet
G. Tattoo/Microchip
H. Vaccine Hx
I. Pet's environment and care
J. Medical or physical conditions - ie. Declawed, deaf, blind, diabetic, epileptic, biter, aggressive, on going medications, etc.
K. Weight

3. All communication with owner - verbally, by phone, in writing..

4. All clinical signs and presenting observations.

5. All physical exams, diagnostic procedures, and laboratory tests.

6. All diagnoses or DDx.

7. All treatment protocols, surgeries, euthanasias, necropsies.

8. All daily observations of hospitalized pets and their health progress.

9. All prescriptions - with complete information.

10. All client completed forms and signed consents.

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