N.M. Admin. Code § 16.25.9.21

Current through Register Vol. 35, No. 21, November 5, 2024

Section 16.25.9.21 - RECORD KEEPING

A. Every veterinarian involved in a veterinarian-client-patient relationship performing any service requiring a license to work on any animal or group of animals in his custody or in the custody of a veterinary facility, shall prepare a legible individual or group animal and client record concerning the animal(s) which shall contain the following information:

(1) name, address, and phone number of the animal's owner or agent; and

(2) name or identity of animal(s), including species, breed, age, sex, weight, and color where appropriate

(3) The medical record shall contain:

(a) a history of pertinent information as it pertains to the animal's medical status;

(b) notation of the physical examination findings;

(c) treatment or intended treatment plans or both, including medications, medication strengths and amounts administered, dispensed or prescribed and frequency of use as well as method of administration including those medications used for sedation, induction and maintenance of anesthesia;

(d) data and interpretation(s) of diagnostic procedures including but not limited to radiographs, laboratory, ultrasound and ECG;

(e) a diagnosis or tentative diagnosis;

(f) when pertinent, a prognosis;

(g) progress notes and disposition of the case;

(h) beginning and ending dates of custody of the animal with daily notations;

(i) in the case of vaccination clinics, a certificate including the information required by Subsections (1) and (2) above may serve as the medical record;

(j) name or initials of the veterinarian responsible for entries; and

(k) name or initials of all ancillary and authorized individuals responsible for entries.

(4) Group records are acceptable for herds, flocks or litters of animals that lack individual identification by name or that include a number of individuals to which the same medical record applies. Records for surgical procedures that include a description of the procedure, surgical findings when pertinent and response to or recovery from anesthesia shall contain the requirements listed in Subsection (3) above.

B. Record storage.

(1) All records shall be the property of the veterinary facility or practice that created such records and shall be kept where easily accessible for a minimum of four years after the animal's last visit.

(2) Upon closure of a facility or practice, notice must be published twice in the local newspaper announcing where records can be obtained for 90 days.

(3) Copies of records and radiographs or a summary of records will be made available within 10 working days upon the client's written request.

C. Controlled substances.

(1) A separate log shall be maintained on each controlled substance and shall contain the following information:

(a) date and time of administering or date of dispensing;

(b) name of owner or agent;

(c) name or identification of animal;

(d) amount dispensed or administered;

(e) balance remaining; and

(f) authorizing veterinarian and identification of authorized individual dispensing or administering the controlled substance.

(2) For each controlled substance, there shall be an annual inventory that includes:

(a) the date of inventory, May 1 annually, unless prior written notice is submitted to the appropriate agency by the licensee manager;

(b) a physical count identifying the quantity of each controlled substance on hand on the date of inventory;

(c) the "balance remaining" from the individual controlled substance log;

(d) the discrepancy between (b) and (c); and

(e) the percent the annual use (d) represents.

(3) All New Mexico board of pharmacy, New Mexico Controlled Substances Act, federal drug enforcement administration (DEA) and federal food and drug administration requirements shall be complied with, including but not limited to the following:

(a) controlled substances must be kept securely locked in a closet, safe or fixed cabinet;

(b) access to the controlled substance storage area should be restricted to the absolute minimum number of employees;

(c) the recommendation that controlled substances stock is kept to a minimum. Should it be necessary to have a substantial quantity of controlled substances stored in the office or facility, the DEA encourages having security which exceeds the minimum requirements such as a safe and alarm system;

(d) the reporting of lost or stolen controlled substances to the appropriate agency;

(e) the disposal of controlled substances through a DEA licensed disposer; and

(f) the DEA and NMCS licenses shall be kept where easily accessible in the pharmacy area but not in public view.

D. Computer records.

(1) There shall be reasonable security of a facility's computer(s) with access limited to authorized individuals only.

(2) A daily and cumulative monthly back-up on a separate disk, magnetic tape or other acceptable device or method shall be made.

N.M. Admin. Code § 16.25.9.21

16.25.9.21 NMAC - Rp 16.25.9.21 NMAC, 01-17-2014