Medical Records

Who owns the original veterinary medical record?

The veterinary practice

How long must veterinary records be kept in Massachusetts?

4 years

Are veterinary medical records confidential?

Yes, unless released by law or client consent

What must a veterinarian provide when a client requests records?

Copies or summaries with consent

What is the primary purpose of medical records?

Support patient care and continuity

What does VCPR stand for?

Veterinary-Client-Patient Relationship

What is required to establish a VCPR?

Vet exam, clinical judgment, client agreement, and follow-up availability

What is informed consent?

Owner authorization to treat after full disclosure

Who must sign informed consent forms?

A client who is at least 18 years old

What does “If it’s not written, it didn’t happen” mean?

Unrecorded care is not legally recognized

What format is commonly used for progress notes?

SOAP format

What does SOAP stand for?

Subjective, Objective, Assessment, Plan

What should medical record entries be like?

Accurate, objective, and chronological

What is included on a cage card?

Patient name, owner name, reason for visit, and cautions

What is included in discharge instructions?

Home care, medications, and recheck information

What does EMR stand for?

Electronic Medical Records