Wis. Admin. Code Veterinary Examining Board VE 1.52

Current through November 25, 2024

Section VE 1.52 - Records

(1) A veterinarian shall maintain individual patient records on every patient administered to by the veterinarian other than food and fiber patients and equine patients for a period of not less than 3 years after the date of the last entry. The veterinarian shall keep individual client records for equine and food and fiber patients for 3 years after the date of the last entry. A computerized system may be used for maintaining a record, as required under this section, if the system is capable of producing a printout of records contained in such system within 48 hours of a request.

(2) The individual patient record shall contain clinical information pertaining to patients other than food and fiber patients and equine patients with sufficient information to justify the diagnosis and warrant treatment, including information regarding each of the following matters which apply:

(a) Date.

(b) Client name.

(c) Patient identification.

(d) History.

(e) Complaint.

(f) Present illness.

(g) Provisional diagnosis.

(h) Physical examination findings.

(i) Record of client's informed consent by signature and date or other specified means.

(j) Treatment - medical, surgical.

(k) Vaccinations administered.

(l) Drugs prescribed, dispensed or administered, including strength or concentration, route of administration, dosing schedule, number dispensed and number of refills allowed.

(m) Final diagnosis.

(n) Consultation, if any.

(o) Clinical laboratory reports.

(p) Radiographic reports.

(q) Necropsy findings.

(r) Identification of the veterinarian providing the care.

(3) The client record for food and fiber patients shall contain at least the following information which apply:

(a) Date.

(b) Client name.

(c) Type of call.

(d) Individual or herd diagnosis.

(e) Record of client's informed consent by signature and date or other specified means.

(f) Treatment and drugs used including amounts of drugs administered and method of administration.

(g) Drugs dispensed including dosing schedule and number dispensed.

(h) Meat or milk withholdings.

(i) Clinical laboratory reports.

(j) Identification of the veterinarian providing the care.

(4) The client record for equine patients shall contain at least the following information which applies:

(a) Date.

(b) Client name.

(c) Patient identification.

(d) History.

(e) Physical examination findings.

(f) Diagnosis.

(g) Record of client's informed consent by signature and date or other specified means.

(h) Treatment-medical, surgical.

(i) Treatment and drugs used including amount of drugs administered and method of administration.

(j) Drugs dispensed including dosing schedule and number dispensed.

(k) Clinical laboratory reports.

(l) Radiographic reports.

(m) Necropsy findings.

(n) Identification of the veterinarian providing the care.

(5) A veterinarian shall provide access to health care records in accordance with s. 89.075, Stats.

Wis. Admin. Code Veterinary Examining Board VE 1.52

Adopted by, CR 21-062: cr. Register July 2022 No. 799, eff. 8-1-22; correction in (5) made under s. 35.17, Stats., Register July 2022 No. 799, eff. 8/1/2022