Iowa Admin. Code r. 811-12.4

Current through Register Vol. 47, No. 6, September 18, 2024

Rule 811-12.4 - Veterinary medical records

(1)Controlled substances records. The licensed veterinarian must maintain a controlled substance log that contains complete, accurate and readily retrievable records of all controlled substances possessed, administered or dispensed.

a. Each record of a controlled substance that is dispensed must meet all U.S. Drug Enforcement Administration and Iowa board of pharmacy regulations for the controlled substances log.

b. Each log record must include the following information:

(1) Name or identification of the patient.

(2) Client's name and address, if not readily available from the licensed veterinarian's records.

(3) Name, strength and quantity of the controlled substance dispensed.

(4) Date on which the controlled substance was dispensed.

(5) Initials of the dispensing licensed veterinarian or authorized auxiliary.

(6) Name of the prescribing licensed veterinarian.

c. All controlled substances must be kept in a locked storage area, and access to the storage area must be limited pursuant to state and federal laws and regulations.

d. Each package or container in which a controlled substance is stored or dispensed must be clearly labeled pursuant to the requirements set forth in state and federal laws and regulations.

e. Each package or container in which a controlled substance is stored or dispensed must comply with all state and federal packaging requirements and with rule 811-12.2 (169).

(2)Patient records. Patient records are the property of the veterinary practice. Each licensed veterinarian shall maintain for at least five years an easily retrievable record for each patient that receives veterinary services. The record must be available for inspection by the client during normal business hours. The information within patient records is privileged and confidential and cannot be released except by court order, a public health emergency, consent of the client or as otherwise authorized by law. The licensed veterinarian in charge shall provide a copy of the complete record to the client not later than two business days after the licensed veterinarian or practice receives from the client a request for the record. A licensed veterinarian or veterinary practice may have an additional three business days to provide a copy of nondigital diagnostic images. The licensed veterinarian may charge reasonable and customary fees for the copying of records.

a. Records required for patients defined as "livestock" in Iowa Code section 717.1(4) include the following:

(1) Name, address and telephone number of the client.

(2) Name or identity of the patient, pen, herd, flock or group, including the identification number, if any.

(3) Date of service.

(4) Documentation of client consent.

(5) Diagnosis or condition at the beginning of treatment of the patient, including results of tests.

(6) Procedures/indications.

(7) Name of drug or medication and treatment administered indicating dosage, frequency and route of administration.

(8) Withdrawal period.

(9) Record of diagnostic images taken.

(10) Name of attending licensed veterinarian.

b. Records required for other patients include the following:

(1) Name, address and telephone number of the client.

(2) Name and identity of the patient, including the identification number, if any.

(3) Date of birth (or estimated age), sex, species and breed of patient.

(4) Dates of care, custody or treatment of the patient.

(5) A history of the patient's condition as it pertains to the patient's medical status.

(6) Documentation of client consent.

(7) Diagnosis or condition at the beginning of treatment of the patient, including results of tests and body weight.

(8) Surgery record, including preanesthesia medication, anesthesia and the procedure performed.

(9) Name of drug or medication and treatment administered indicating dosage, frequency and route of administration.

(10) Progress and disposition of the case.

(11) Record of diagnostic images taken.

(12) Name of attending licensed veterinarian.

(3)Stored diagnostic images.

a. Each stored diagnostic image must be identified with the following information:

(1) The name of the licensed veterinarian or facility that took the diagnostic image.

(2) The name or identifying number, or both, of the patient.

(3) The name of the client.

(4) The date on which the diagnostic image was taken.

(5) The anatomical orientation depicted by the diagnostic image.

b. Stored diagnostic images must be retained for at least five years.

c. A stored diagnostic image of the patient or a copy must be released, upon the written or verbal request, to another licensed veterinarian who has the authorization of the client. Original diagnostic images shall be returned in a reasonable time.

(4)General anesthesia. General anesthesia is a condition caused by the administration of a drug or combination of drugs sufficient to produce a state of unconsciousness or dissociation and blocked response to a given pain or alarming stimulus. The following standards relating to general anesthesia apply:

a. Within 12 hours prior to the administration of a general anesthetic, the patient must receive a physical examination, with the results noted in the patient's medical records.

b. The patient under general anesthesia must be under observation for a length of time appropriate to the species for the patient's safe recovery.

c. The licensed veterinarian must provide a method of respiratory monitoring that may include observing the patient's chest movements, observing the rebreathing bag or using a respirometer.

d. The licensed veterinarian must provide a method of cardiac monitoring, which may include the use of a stethoscope or electrocardiograph monitor.

Iowa Admin. Code r. 811-12.4

ARC 1465C, IAB 5/28/2014, effective 7/2/2014

Amended by IAB February 24, 2021/Volume XLIII, Number 18, effective 3/31/2021

Adopted by IAB May 15, 2024/Volume XLVI, Number 24, effective 7/1/2024