La. Admin. Code tit. 46 § LXXXV-701

Current through Register Vol. 50, No. 11, November 20, 2024

Section LXXXV-701 - Record Keeping

A. It shall be considered unprofessional conduct within the meaning of R.S. 37:1526(14) for a licensed veterinarian to keep improper records. The purpose of these regulations is to produce a record such that a veterinary peer can, by using said records, gain a full understanding of the findings, diagnostic process, reasons for treatment protocol, and applicability of surgical procedures. Records shall be legible, and established and maintained as follows.

1. Each Louisiana licensed veterinarian shall maintain an individual written, or computer generated, record on each animal or herd to include identification of animal or herd, diagnosis of illness, disease or condition and treatment provided, progress notes and reassessment, and discharge summary, as follows.

a.

i.Identification of the animal or herd shall include the breed, sex, description or permanent identification (if available), tattoos or other identifying marks, and the name and address of the owner.

ii. Diagnosis of illness, disease or condition shall document the animal or herd's history, signs, symptoms, complaints, objective tests such as radiographs and laboratory results, and the veterinarian's interpretation of examination findings, as well as intended goals and treatment including surgical procedures and/or drug therapy. Drug therapy shall include the names of legend drugs, controlled substances and/or over-the-counter (OTC) products as set forth below; the date and amount administered, prescribed or dispensed; and the method of administration.

iii. A progress note shall document the animal or herd's subjective status, changes in objective findings, and progression or regression of goals and treatment. A progress note shall be documented for each visit, for continuation of treatment, for the particular diagnosed illness, disease, or condition.

iv. Reassessment shall include all elements of a progress note, as well as a revision of the treatment plan as indicated. A new diagnosis of illness, disease or condition may be warranted. Reassessment shall only be performed by the veterinarian. Reassessment, including a new diagnosis of illness, disease, or condition when applicable, shall be documented at the time such is performed.

v. Discharge summary shall document the reasons for discontinuation of care, degree or goal of achievement, and a discharge plan, if required, which shall only be documented and signed by the attending veterinarian.

vi. The documentation standards set forth above do not mandate a particular format, however, a record must include these elements, as well as any other document required by law or the board's rules. Examples include General Anaesthesia Consent Forms, Euthanasia Consent Forms, documents involving prescribing, administering, or dispensing legend drugs or controlled substances, and billing invoices or statements of services or products provided. The veterinarian shall be ultimately responsible for the content and maintenance of the record.

b. records shall be maintained for at least five years, including records of large animal and/or herd type practice;

c. the record keeping requirements contained in §701 do not apply to Over-the-Counter (OTC) products except:

i. if an OTC product has been prescribed by the licensed veterinarian as part of a treatment regimen, then the sale and instructions must be recorded in the medical record in accordance with §701. A.1 a; or

ii. if a licensed veterinarian dispenses an OTC product and directs the client to use the product in any manner not on the product's label, then the product must be treated as a legend drug and its use must be properly recorded in the animal's medical record in accordance with §701. A.1 a

2. Radiographs shall be kept in the following manner:

a. marker must have name of hospital and/or clinician;

b. marker must have identification of the animal, i.e., number and/or owner's name;

c. marker must have date radiograph was made;

d. radiograph must be properly identified with "L" for left and "R" for right;

e. radiograph must be kept for at least five years.

B. Maintenance, Ownership, and Release of Records

1. Patient records shall be maintained for a period of five years and are the responsibility and property of the veterinarian. The veterinarian shall maintain such records and shall not release the records to any person other than the client or a person authorized to receive the records for the client.

2. The veterinarian shall provide any and all records as requested by the board to the board. Failure to do so shall be considered unprofessional conduct.

3. The records of a veterinary facility are the sole property of that facility, and when a veterinarian leaves salaried employment or contract services therein, the departing veterinarian shall not copy, remove, or make any subsequent use of those records. The copying, removal, or any subsequent use of those records by the departing veterinarian shall be considered a violation of the rules of professional conduct within the meaning of R.S. 37:1526.

C. Copies or synopsis of patient records shall be provided to the client or the client's authorized representative upon request of the client. A reasonable charge for copying and providing patient records may be required by the veterinarian. Refusal to provide such records upon written request by the client shall be considered a violation of the rules of professional conduct within the meaning of R.S. 37:1526. A synopsis record shall include at a minimum the following information:

1. name or identification of animal or herd;

2. name of owner;

3. all dates of treatment;

4. the complaint;

5. any abnormal findings;

6. diagnosis; and

7. therapy; including:

i. the amount administered; and

ii. the method of administration of:

(a). all drugs;

(b). chemicals; and

(c). medications; and

8. surgical procedures performed for each date of treatment.

D. A consultant veterinarian who dispenses a legend drug upon authorization of the primary care veterinarian must establish a patient record and/or dispensing log which shall contain at least the following information:

1. name of patient and/or other identification;

2. breed;

3. sex;

4. name of client/owner;

5. name of drug dispensed;

6. amount dispensed;

7. date dispensed;

8. name of the patient's primary care veterinarian; and

9. his/her diagnosis or therapy regime for which the drug being dispensed has been prescribed.

La. Admin. Code tit. 46, § LXXXV-701

Promulgated by the Department of Health and Human Resources, Board of Veterinary Medicine, LR 6:71 (February 1980), amended by the Department of Health and Hospitals, Board of Veterinary Medicine, LR 16:225 (March 1990), LR 19:1328 (October 1993), LR 20:1381 (December 1994), LR 23:969 (August 1997), LR 24:941 (May 1998), LR 25:872 (May 1999), LR 33:2424 (November 2007).

AUTHORITY NOTE: Promulgated in accordance with R.S. 37:1518 et seq.