Professional Practice Standard
Published: December 2014
Revised: November 2015
The complete medical record is a compilation of all information that pertains to the care of an animal or a group of animals, and documents the management of a case. It is a legal document that represents the veterinarian’s thought process, decisions, judgment, actions, and interactions with others (clients, colleagues, other caregivers, and service providers such as specialists and laboratories), each of which has an impact on patient outcomes. The medical record is also a communication tool which facilitates the continuity of care for animals both within and between veterinary medical-care teams.
A quality record is fundamental to quality practice, and this Professional Practice Standard itemizes the essential elements of a quality record. As such, justification for any departure from this Professional Practice Standard should be documented in an appropriate place within the medical record.
The Professional Practice Standard: Medical Records applies to all veterinarians and all record systems (e.g., electronic, paper or combination of both). Information requirements for specific species is found in Ontario Regulation 1093.