18 Va. Admin. Code § 150-20-195

Current through Register Vol. 41, No. 6, November 4, 2024

Section 18VAC150-20-195 - Recordkeeping

A. A legible, daily record of each patient treated shall be maintained by the veterinarian at the registered veterinary establishment and shall include at a minimum:

1. Name of the patient and the owner;

2. Identification of the treating veterinarian and of the person making the entry (Initials may be used if a master list that identifies the initials is maintained.);

3. Presenting complaint or reason for contact;

4. Date of contact;

5. Physical examination findings;

6. Tests and diagnostics performed and results;

7. Procedures performed, treatment given , and results;

8. Drugs administered, dispensed, or prescribed, including quantity, strength and dosage, and route of administration. For vaccines, identification of the lot and manufacturer shall be maintained;

9. Radiographs or digital images clearly labeled with identification of the establishment, the patient name, date taken, and anatomic specificity. If an original radiograph or digital image is transferred to another establishment or released to the owner, a record of this transfer or release shall be maintained on or with the patient's records; and

10. Any specific instructions for discharge or referrals to other practitioners.

B. An individual record shall be maintained on each patient, except that records for economic animals or litters of companion animals under the age of four months may be maintained on a per owner basis. Patient records, including radiographs or digital images, shall be kept for a period of three years following the last office visit or discharge of such animal from a veterinary establishment.

C. An initial rabies certification for an animal receiving a primary rabies vaccination shall clearly display the following information: "An animal is not considered immunized for at least 28 days after the initial or primary vaccination is administered."

18 Va. Admin. Code § 150-20-195

Derived from Virginia Register Volume 15, Issue 5, eff. December 23, 1998; amended, Virginia Register Volume 19, Issue 9, eff. March 1, 2003; Volume 21, Issue 23, eff. October 8, 2005; Volume 26, Issue 4, eff. November 25, 2009; Amended, Virginia Register Volume 34, Issue 01, eff. 10/25/2017.

Statutory Authority: § 54.1-2400 of the Code of Virginia.