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13. Clinical and client records

Updated 10 June 2014

13.1  Clinical and client records should include details of examination, treatment administered, procedures undertaken, medication prescribed and/or supplied, the results of any diagnostic or laboratory tests (including, for example, radiograph, ultrasound or electrocardiogram images or scans), provisional or confirmed diagnoses, and advice given to the client. It is prudent to include plans for future treatment or investigations, details of proposed follow-up care or advice, notes of telephone conversations, fee estimates or quotations, consents given or withheld and contact details. Ideally, client financial information should be recorded separately from clinical records. 

13.2  The utmost care is essential in writing case notes or recording a client's personal details to ensure that they are accurate and that the notes are comprehensible and legible. Clinical and client records should be objective and factual, and veterinary surgeons should avoid making personal observations or assumptions about a client’s motivation, financial circumstances or other matters.

13.3  Clinical and client records including radiographic images and similar documents, are the property of, and should be retained by, veterinary surgeons in the interests of animal welfare and for their own protection.

13.4  Copies with a relevant clinical history should be passed on request to a colleague taking over the case.

13.5  Where a client has been specifically charged and has paid for radiographic images or other reports, they are legally entitled to them. A practice may choose to make it clear to clients that they are not charged for radiographs or laboratory reports, but for diagnosis or advice only.

13.6  The Data Protection Act 1998 gives anyone the right to be informed about any personal data relating to themselves on payment of an administration charge. At the request of a client, veterinary surgeons must provide copies of any relevant clinical and client records, including radiographic images and similar documents. This also includes relevant records which have come from other practices, if they relate to the same animal and the same client, but does not include records which relate to the same animal but a different client.

 

Vaccination record cards

13.7  A vaccination record card held by the animal owner may be considered part of the clinical record and may be signed by a veterinary surgeon or a veterinary nurse (see supporting guidance 18.10  18.12). If a veterinary nurse signs the record, it is good practice to add the words ‘under the direction of ...’ and name the directing veterinary surgeon.

13.8  The animal should be identified on the vaccination record card and the principles set out in RCVS advice on identification of animals (see supporting guidance 21.12 – 21.15) should be followed. These state:

21.12  If an alleged identification mark is not legible at the time of inspection, no certificate should be issued until the animal has been re-marked or otherwise adequately identified.  

21.13  When there is no identification mark, the use of the animal's name alone is inadequate. If possible, the identification should be made more certain by the owner inserting a declaration identifying the animal, so that the veterinary surgeon can refer to it as 'as described'.  Age, colour, sex, marking and breed may also be used.

21.14  The owner's name must always be inserted. (In the case, for example, of litters of unsold puppies this will be the name of the breeder or the seller.)

21.15  Where microchipping or tattooing has been applied it should be referred to in any certificate of identification. 

13.9  The animal may be presented to a different veterinary surgeon for a subsequent vaccination. To be useful, the vaccination record should be such as to allow the veterinary surgeon to identify the animal, if necessary, following any additional reasonable enquiries. Veterinary surgeons should not sign blank vaccination record cards.  

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