Guide - Medical Records

Yes, medical records are legal documents. They represent the veterinarian’s thought process, decisions, judgment, actions, and interactions with others all of which have an impact on patient outcomes. The language used when documenting medical record information should always be professional and objective. Comprehensive patient records are a good risk management strategy.

A medical record may include, but is not limited to, the following documents: 

• client and patient information forms
• emergency contact and authorized agent
• information forms
• client communications
• cumulative patient profile/master problem list
• vaccine record
• progress notes
• monitoring forms
• Protocols
• laboratory reports
• diagnostic images (such as radiographs and ultrasounds)
• invoices
• insurance documents
• consent forms
• health certificates
• certificates of rabies vaccination
• referral letters to and from others
• export documents
• an audit trail (usually in electronic records)
• copies of records from previous facilities (if any) 

For more information, please review the components listed in the Case Cover Sheet provided for Peer Review of Medical Records, found on the College’s website.

To be complete, patient records do not necessarily have to be lengthy. Quantity of record information does not necessarily equate to completeness. For a record to be comprehensive, ensure that:  

• The regulatory requirements are met;
• There is enough detail to maintain continuity of patient care; and
• There is an understanding of the veterinarian’s thought process and reasoning behind a diagnosis and decision for treatment plans.

Veterinarians may use a variety of strategies or tools to ensure that records are complete and concise. Organizational formats for record-keeping include Subjective-Objective-Assessment-Plan (SOAP) or Data-Assessment-Plan (DAP). In addition, the use of tools such as master problem lists/cumulative patient profiles, protocols, templates, and checklists contribute to the efficient collection of information and a sufficiently documented record. Examples can be found on the College website.

Subjective: The history documenting and describing the presenting complaint and recent health status of the animal(s) or group of animals. 
Objective: Documentation of physical examination findings that indicates which body systems were examined. Abbreviations such as PE-NAF or PE-NSF are not sufficient documentation unless a protocol detailing what is covered in the examination is referenced in the record. Any diagnostic test results.
Assessment: Information and reasoning on how the veterinarian arrived at a diagnosis should be recorded. This includes the recording of problem lists, differential/working diagnoses and regular updates as more information is gathered. Sufficient information demonstrating that the veterinarian has reviewed and interpreted data from diagnostic tests to confirm a diagnosis.
Plans: Recommendations and treatments provided describing tests, drugs, treatments, surgical or medical procedures, referrals for specialized care and a follow-up schedule. Client communication and professional advice provided.
* Note that if using the DAP format, the information in subjective and objective above would be captured in “D” for data.

Yes. Protocols can be developed and used for completeness and efficiency. A protocol is a detailed description of a procedure that is done routinely. Protocols can be developed for surgical procedures, physical examinations, vaccination administration, etc. A notation in the patient record would indicate that a procedure was done “as per protocol” and any information specific to the patient and/or any variation in the protocol would be recorded.

A library of all protocols, inclusive of the date of each version, should be maintained in the facility for reference purposes. A protocol, despite revisions, must be maintained for as long as any medical records that refer to it are kept.

Examples of protocols can be found on the College website.

It is not sufficient to include only reports of test results. The record should reflect the veterinarian’s interpretation of the test results. This data would be used to update the assessment of the animal(s) or group of animals. For example, revising the problem list and differential/working diagnoses or documenting a diagnosis. There should also be documentation that the client was notified of the results and any additional plans related to patient care.

When documenting client information, each owner should be recorded (name, address, and contact information) and their contact information updated regularly. It should be clear in the record who is the owner(s) of the animal(s) or group of animals. Simply adding a name under “client” “spouse” “other” or even “emergency contact” may not accurately reflect who is the rightful owner of the animal.

For a sample template to document information about clients, owners, and authorized agents see the Sample Form Client Patient Identification on the College website.

It is important to note that when a client requests the removal of another client from the client information in the record, this requires the consent of all listed clients. A veterinarian should not remove the name of a client on a file unless they have received consent from the person in question. The client(s) can remove the name of an authorized agent without the consent of the authorized agent.

Example One: A person presents an animal for an appointment and client information is confirmed by the veterinarian. The person presenting the animal clarifies that the animal is owned by their adult child. The veterinarian records the name, address and contact information of the child in the record as the client and the owner of the animal. They also document the name, address and contact information of the person presenting the animal and their relationship with the client. They confirm with the child that their parent is an authorized agent and documents which medical and financial decisions the parent is permitted to make at any time.

Example Two: A veterinarian provides veterinary care to several horses at a barn. Each horse is owned by a different person; each horse owner is a client and has their own medical record for their horse at the practice; each medical record lists the manager of the barn as an authorized agent. The medical records for each horse belong to the client, who is also the horse owner, and each client has indicated what care and financial decisions the manager can make on their behalf.

When a client is unavailable, an authorized agent is a person authorized by the client(s) to act on their behalf and whose decisions bind the client(s) as though they were themselves making the decisions. An authorized agent of the client(s) should also be clearly documented, including their contact details and updated regularly. A veterinarian should also document what kinds of decisions the agent has been authorized by the client(s) to make, such as medical and financial decisions.

For a sample template to document information about authorized agents see the Sample Form Client Patient Identification on the College website.

Yes. A medical record includes documentation regarding verbal communication with a client and copies of written communications. This includes face to face, telephone, electronic, and other mechanisms to communicate with clients and/or authorized agents. Records should document advice provided and informed consent discussions, including diagnoses, treatment plans, required tests and interpretation of results, referrals, and discharge directions. Copies of any documents provided to the client such as discharge instructions, insurance forms, and client education material for example, should be maintained in the patient record.

Obtaining informed client consent always needs to be documented, either as a copy of a signed consent form or as notes in a patient record indicating that the client gave verbal consent (with a description of the discussion). Further information regarding documentation of informed client consent can be found in the Guide to the Professional Practice Standard: Informed Client Consent which is located on the College’s website.

Fees and charges for all services and drugs must be documented in the medical record. This information is most often recorded on invoices as an itemized list of drugs and services that were provided. Other areas in the record where this information may be found are on treatment estimates or directly in the progress notes.

It must be clear in the medical record that fees for drugs are distinct from the fees for services.

Charges for services that are provided by third parties and invoiced by the practice should also appear as separate fees, such as external laboratories, itinerant veterinarian fees, cremation services, etc.

Fees on the invoice should be easily cross-referenced with all treatments and procedures described in the medical record.

Ontario Regulation 1093 Section 22 and the facility standards for veterinary facilities require that medical records include “fees and charges, showing separately those for drugs and those for advice or other services.”
The following guidance is provided to assist with satisfying this requirement.

• When a drug is dispensed to the client, the name of the drug and its associated fee should be documented on the invoice.
• When a drug is administered by the veterinarian, it is sufficient to document the category of the drug that was administered on the invoice and its associated fee, such as “pain medication”, or “antibiotic”. Alternatively, the name of the drug can be documented.
• Where the category of drug is on the invoice, the name of the drug is required to be documented elsewhere in the record.
• Consider avoiding terms that may suggest the combining of services and drugs, such as “anesthetic induction”. To some, this may refer to the drug and the administration of the drug to induce anesthesia.
• If including multiple services and drugs into one fee on the invoice, an itemized list of services and drugs and their associated fees that are included should be documented separately (such as a protocol) and available if the client requests it.
• Dispensing fees may be incorporated into drug costs or itemized separately. When incorporated into a drug cost, it should be noted that the price includes a dispensing fee.

See sample invoices on the College website.

Veterinarians demonstrate professionalism by being accountable and transparent in relation to the services they provide.

When a client is charged a fee related to a third-party service, such as the fee of an itinerant veterinarian, the fee cannot be marked up. The practice may charge the client reasonable administrative fees associated with providing that service (e.g., facility space, staff time, etc.) and these should appear as separate invoice items.

Yes, a veterinarian is required to provide a copy of the requested components of the medical record to a client upon request. This includes a request for a copy of the complete medical record.

The original physical and/or electronic copy of the medical record must be retained by the veterinary facility. A veterinarian is required to keep the originals of all records in accordance with the College’s retention standards. The information contained in the record belongs to the client and the client has the right to access the content of the record.

A veterinarian can request the transfer of a medical record when they are treating an animal(s) or group of animals that has previously received care from another veterinarian. The request is made in an attempt to facilitate and coordinate current patient care.

A veterinarian is not required to obtain client consent to release medical record information if the request from another veterinarian is to facilitate and coordinate current patient care in cases where the record relates to the same client.

A veterinarian is not required to obtain client consent to release medical record information when:

• Requested by another veterinarian to facilitate and coordinate patient care in cases where the record relates to the same client;
• Required or authorized to do so by law, which is inclusive of appropriate release to the police, a provincial animal welfare (PAWS) inspector, or animal control;
• Helping to prevent or assisting in the treatment of a person with a disease or physical injury, such as reporting any knowledge of any animal bite, or a contact that may result in rabies in persons to a local Medical Officer of Health. (For more information please refer to the Legislative Overview: Rabies found on the College website);
• Identifying, locating, or notifying the apparent owner of the animal(s) or group of animals, protecting the rights of the apparent owner, or
• enforcing applicable laws with respect of the animal, where it appears that the animal(s) or group of animals is not owned by the person who has presented it for treatment;
• Requested or consented to by a previous client for the part of the record that was created during the period of time that they were the client on the medical record; or
• Requested by the College of Veterinarians of Ontario.

No. A request for a medical record may be made by telephone, facsimile, email, regular mail, in-person contact, or by any other means. 

Veterinarians are permitted to charge a reasonable fee to recover the cost of making a copy of a medical record (i.e. materials, staff time, courier/postage fees etc.). Clients should be informed of this fee and made aware that payment is not a pre-requisite for providing the copy of the record in a timely manner.

A veterinarian must not obstruct the efficient and timely release of information due to any outstanding fees that a client may owe. This includes a client’s refusal to pay for the copy of the medical record.

A veterinarian is expected to respond to a request in a timely manner to enable continuity of care. Requests to transfer a complete copy of a’ medical record should be completed within two (2) business days. In urgent cases, such as an emergency, relevant information can be provided verbally, with a copy of the medical record to follow.

A veterinarian is required to provide relevant historical (i.e. medical) information when requested by another veterinarian treating the animal(s) or group of animals. This may involve providing the entire medical record but can also include medical summaries or a portion of the medical record based upon the request being made.

For example, if the treating veterinarian is providing a second opinion about a specific condition, they may only require information that pertains to that condition. Another example is a referral to a specialist. This many only require that certain aspects of the medical history be provided.

A conversation between the veterinarians and/or client will assist with ensuring that the information that is required is available to coordinate care for the animal(s) or group of animals. The individual making the request can also be specific about what information is required.

There will be times when the veterinarian requesting the information determines that the full record is  needed to coordinate care. The client also maintains the right to request a full copy of an animal(s) or group of animals medical record for any reason. In these circumstances, the full record must be provided.

A veterinarian is required to provide radiographs if they are relevant to the request. For digital radiographs, a copy of the digital image may be provided. For film radiographs, a veterinarian may mail the original radiographs directly to the requesting veterinarian or client with a request for their return. If this is not practical, then the client can be asked to personally transfer the radiographs as long as a release is signed stating that the radiographs will either be returned or permanently transferred to the requesting veterinarian. Alternatively, digital photos of film radiographs may be forwarded. All digital copies of radiographs must preserve the quality of the image and prevent it from being altered.

When treating an animal(s) or group of animals that has previously received treatment from another veterinarian, a veterinarian is required to notify the previous veterinarian and obtain relevant historical (i.e. medical) information as soon as practicable. After receiving the request, the previous veterinarian is required to provide information that is relevant to the request.

Example: Dr. X sees a new client and patient at their hospital to examine an unresolved lameness issue. Dr. X contacts Dr. Y who previously treated the patient to request relevant historical (i.e. medical) information. Based on the reason for the visit, Dr. X determines that it is necessary to review any visits to Dr. Y that relate to the lameness issue, any tests that were performed, treatments that were done (including any drugs prescribed, dispensed or administered), and the patient’s vaccine history. Dr. X contacts Dr. Y to request this information. Dr. Y has their staff prepare the relevant records and sends them to Dr. X within two business days.

When a new client makes an appointment with a veterinarian, there is the intent to establish a veterinarian-client-patient relationship (VCPR). During the contact with a new client, the veterinarian and/or staff can inform the client that they will need to contact their previous veterinarian and obtain relevant historical (i.e. medical) information on their animal(s) or group of animals. The reason for this is care coordination. Alternatively, they can ask the client to bring their animal(s)’ or group of animals medical record with them to the appointment or to provide it before the appointment.

There may be circumstances where a new client refuses to have further communication with the previous veterinarian, including requesting their’ previous record. They may also indicate that they do not wish for the new veterinarian to contact their previous veterinarian. In these circumstances, the new veterinarian is obligated to inform the client that uncoordinated care puts their animal(s) or group of animals at risk. If the client still refuses, the veterinarian can still proceed with seeing the patient if they choose to do so. The veterinarian must not break confidentiality or privacy by seeking the information when the client has withdrawn their consent.

Example: Dr. X is seeing a new client and patient. Dr. X’s staff have requested that the new client bring the patient’s previous medical history to the appointment. The client brings invoices and vaccine certificates from the previous veterinarian that they kept at home. Dr. X informs the client that they also need to see previous lab tests that were performed, including x-rays and bloodwork. Dr. X informs the client that they can contact the previous veterinarian for this information. The client indicates that they do not want Dr. X to contact the previous veterinarian. Dr. X informs the client about the importance of having this information to coordinate care and prevent duplication of tests. The client still refuses. Dr. X asks the client if they are willing to proceed with the appointment which involves taking a complete history and performing a complete examination of the patient and that this may indicate that lab tests are needed to determine further care. The client agrees to continue with the examination.

It is not the responsibility of the veterinarian receiving the request for a record to determine if client consent has been provided. It is only when there are reasonable grounds to believe that the requesting veterinarian has not obtained at least implied consent, or where the client has withdrawn consent, that the responding veterinarian may refuse or delay transmission of information until confirmation can be sought from the client. Even here, the request for confirmation from the client should not amount to an attempt by the responding veterinarian to dissuade the client from exercising their right to consult with another veterinarian.

Example: Dr. X recently had a client request a transfer of their herd’s medical record to another veterinarian, Dr. Y. Dr. X calls Dr. Y and requests that they provide a copy of the herds’ records to add to their own file on the animals. Dr. Y asks Dr. X if the client has an appointment with their clinic. Dr. X tells Dr. Y that there is no appointment but that they are still a client. Dr. Y informs Dr. X that the client indicated that they did not wish to return to Dr. X’s practice. Therefore, Dr. X is not entitled to a copy of the records since Dr. X will not be treating the patient. If in the future the client makes an appointment to see Dr. X again, then Dr. X can request relevant historical (i.e. medical) information from Dr. Y.

Yes. The information in the medical record belongs to the client who is documented in the medical record.

If a new owner establishes a veterinarian-client-patient relationship (VCPR) at a different practice and requests the records from the practice where the previous owner is identified as the client, the veterinarian must obtain consent from the previous owner to release the records.

A veterinarian must ensure that records are complete and up-to-date. Records should be created or updated immediately or as soon as possible after contact with the patient or client or new information is received. Timely recording of information minimizes the risk of incomplete records and ensures current information is available to all members of the veterinary team.

There are situations when it is necessary for a veterinarian to change a medical record to ensure that the correct information is recorded. Whether making a correction in electronic records or paper-based records, a veterinarian must not delete or make the original information illegible when making a correction.

Paper-based Records: Corrections should be documented with the date of the change, the initials/name of the person making the change and a notation explaining the reason for the change. It is sufficient to strike a single line through incorrect information in paper-based records. The original information must remain legible.

Electronic Records: Electronic records should establish an audit trail that documents the change and retains the original information. A veterinarian must be familiar with the auditing capabilities of their software system, for example:

Some systems have an on/off feature for preserving the original content of records.

Other systems have a time-out feature or locking feature – this feature can be set so the system will time-out after a period of inactivity. The veterinarian must then sign back into the system to make the next entry.

If a software system does not have auditing capabilities, then a correction to the record can be documented as an addendum with the date of the change, the initials/name of the person making the change, reference to the entry being modified, and a notation explaining the reason for the change.

While some systems maintain an audit trail external to the main record, it is still considered part of the record. When making copies of electronic records, the audit trail must be accessible and capable of being printed.

Any person (e.g., veterinarians, technicians, other staff) who makes an entry in a medical record should be authorized to have access to the record. Whenever information is entered into the record, the entry should be documented with the initials of the person making the entry and the date the entry was made. For electronic records, the software should have the capacity to track and record who enters information and when it is recorded.

While aspects of medical record documentation can be delegated to auxiliary staff, a veterinarian remains responsible and accountable for the information recorded in the medical record. Veterinary oversight is required to ensure auxiliary staff members understand the requirements and expectations for documenting a complete medical record.

The language used by all staff members when writing in a medical record should be professional and objective and should avoid subjective and derogatory comments. A medical record is a permanent and legal record and it is important to ensure that the tone is professional in nature.

Appropriate steps must be taken to protect patient and client confidentiality regardless of whether records are paper-based or electronic. Physical and visual access to records should be limited to veterinarians and authorized staff.

Paper-based records should be stored in secure, fire-proof cabinets that are locked when not in use. Electronic records should be encrypted, and back-ups made and stored off-site. Passwords need to be secure and changed on a regular basis. Paper records and electronic equipment (e.g., laptops, USBs, etc.) must be securely stored when in transport.

Medical records must be retained for a period of at least five years after the date of the last entry in the record or until two years after the member ceases to practice veterinary medicine, whichever occurs first. The veterinarian needs to ensure that the method of storage of records is secure, confidential, and accessible to them and the client upon request.

Radiographs are to be retained for as long as a patient record is retained, regardless of the date the radiograph was taken. For example, if a radiograph was taken more than five years ago but the patient record is still active, then the radiograph must be kept. Once a patient record can be purged (five years after the last entry), then all radiographs associated with that patient record can be purged.

Veterinarians who close a facility must arrange for medical records to be stored for up to two years after the practice closes. The veterinarian needs to ensure that the method of storage of records is secure, confidential, and accessible to them and the client upon request. Clients and the College of Veterinarians of Ontario should be notified about how to access medical records.

No. A veterinarian is required to retain a complete copy of the medical record for at least five years after the date of the last entry in the record or until two years after the member ceases to practice veterinary medicine, whichever occurs first.

Scanned paper documents should be converted to read-only electronic formats. Once scanned, the original copy may be destroyed in a manner that protects privacy and confidentiality. Radiographs must be kept in their original format.

Yes, a veterinarian who provides veterinary services in a temporary facility is not required to adhere to the full medical records requirements in respect of animals receiving services at the temporary facility.

In addition, for a veterinarian providing services that are permitted or required under the Dog Owners’ Liability Act, the Animals for Research Act, the Provincial Animal Welfare Services Act, the Animal Health Act or under any other Act except for the Veterinarians Act or for a veterinarian who is retained or employed by a person other than an animal(s)’ or group of animals owner to conduct an independent examination and report on the animal(s) or group of animals health to that person, the medical record must contain only as much information as can reasonably be obtained in the circumstances. The records must be legibly written or typed, kept in a systematic manner, identified after each entry with the initials or code of the veterinarian responsible for the procedure (in practices of more than one practitioner or in practices that employ locums) and retained for a period of at least five years after the date of the last entry in the record or until two years after the member ceases to practise veterinary medicine, whichever occurs first. In addition, the records must adhere to the normal requirements regarding updating records and recording and maintaining electronic records.