1. The veterinary surgeon/client relationship is founded on trust, and in normal circumstances a veterinary surgeon must not disclose to any third party any information about a client or their animal either given by the client, or revealed by clinical examination or by post-mortem examination. This duty also extends to associated support staff.
2. In circumstances where the client has not given permission for disclosure and when the veterinary surgeon believes that animal welfare or public interest are compromised the RCVS may be consulted before any information is divulged.
3. Permission to pass on confidential information may be express or implied. Express permission may be either verbal or in writing, usually in response to a request. Permission may also be implied from circumstances, for example in the making of a claim under a pet insurance policy, when the insurance company becomes entitled to receive all information relevant to the claim and to seek clarification if required.
4. Registration of a dog with the Kennel Club permits a veterinary surgeon who carries out surgery to alter the natural conformation of a dog, or a caesarean operation on a bitch, to report this to the Kennel Club
5. Case records including radiograph films 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. Copies with a summary of the history should be passed on request to a colleague taking over the case.
(N.B. Where a client has been specifically charged and has paid for radiographs or other reports, they are legally entitled to them. The practice may however choose to make it clear that they are charging not for the radiographs, but for diagnosis or advice only. In appropriate circumstances they may be prepared also to provide copies of the radiographs)
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.
7. At the request of a client, veterinary surgeons must provide copies of any relevant clinical records; this includes relevant records which have come from other practices, if they relate to the same animal and the same client. It does not include records which relate to the same animal but a different client. Where any significant expense is involved in providing such copies, as there might be, for example, with the provision of radiographs, a charge can be made. Expense should not be a reason for declining to provide copies.
8. It follows that the utmost care is essential in writing case notes or recording a client's personal details to ensure that the latter are accurate (particularly in relation to financial details) and that the notes are comprehensible and legible.
9. Disclosure of records may be ordered in disciplinary or court hearings, and the RCVS may request copies of case records routinely in the course of investigating a complaint.
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