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13. Clinical and client records
Updated 25 October 2017
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 (whether over the telephone or in person). They should also include outline 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, contact details and any recommendations or discussion about referral or re-direction.
13.2 The utmost care is essential in writing records or recording a client's personal details to ensure that they are clear, accurate and appropriately detailed. Clinical and client records should be objective and factual, and veterinary surgeons and veterinary nurses should avoid making personal observations or assumptions about a client’s motivation, financial circumstances or other matters.
13.3 Ideally, client financial information and any other personal or sensitive information should be recorded separately from clinical records. This is because only relevant clinical information / information in the interests of the treatment of the animal should be provided to colleagues taking over responsibility for a case. It is however acceptable to include a statement in the clinical records that treatment has been limited or declined by the client for financial or other reasons.
Amendments and additions
13.4 Clinical and client records should be made at the time of the events being recorded or as soon as possible afterwards. There may however be justifiable reasons to retrospectively amend clinical records, for example, in order to correct an inaccurate entry or to include additional information. In such cases, the amendment, the details of the person making the amendment and the date on which it is made should be clearly marked. Any correction should, where possible, be noted alongside the relevant entry. Care should be taken not to obliterate the original entry. This is to avoid giving rise to allegations that the amendments have been made unprofessionally or dishonestly.
13.5 Veterinary surgeons and veterinary nurses should take extra care when using older electronic records systems, which allow for the deletion or over-writing of the previous records. This is to ensure that mistakes and inadvertent amendments are not made.
13.6 If multiple team members are involved in updating the same clinical record, it is important to make sure that the identity of the person making the entry is clear.
Dealing with factual inaccuracies
13.7 In some cases, clients may consider that information contained within the records is inaccurate or incorrect and may request that the information be corrected. If a client objects to or complains about an entry in their records, veterinary surgeons and veterinary nurses should discuss the client’s concerns with them and make a record of the discussion. It should be noted, however, that diagnosis and clinical opinion is a matter of clinical judgement and should not be changed solely at the client’s request. There is no obligation to amend professional opinion. If, however, the veterinary surgeon or veterinary nurse agrees that the records should be amended due to errors or factual inaccuracies, the advice above should be followed.
13.8 If, after discussion and following the steps above, the client remains dissatisfied, the most appropriate course of action may be to insert the client’s opinion alongside that of the veterinary professional, making it clear that the additions were inserted at the client’s request. It is helpful to remind the client that an alteration to an electronic record is always preserved (together with the original entry) as part of the audit trail.
Access to clinical records
13.9 Clinical and client records including diagnostic images and similar records, are the property of, and should be retained by, veterinary surgeons in the interests of animal welfare and for their own protection. Although clients do not own their clinical records, they have the right to access information about themselves under data protection legislation as well as under professional guidelines set by the RCVS.
13.10 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. Veterinary surgeons and veterinary nurses should comply with data protection legislation, including any advice from the Information Commissioner’s Office (ICO) regarding subject access requests.
13.11 Under RCVS guidelines, at the request of a client, veterinary surgeons and veterinary nurses must provide copies of any relevant clinical and client records. This 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.
13.12 In many cases it will be made clear to clients that they are not being charged for radiographs or laboratory reports, but for diagnosis or advice only. In situations where images are held on film, the film remains the property of the practice, with the client being charged for diagnosis or advice. In this situation, copies should still be provided in response to a request, wherever possible. Where images are held digitally, clients are also entitled to a copy.
13.13 Relevant clinical information should be provided promptly to colleagues taking over responsibility for a case and proper documentation should be provided for all referral or re-directed cases. Cases should be referred responsibly (Referrals and second opinions). Additional requests for information should also be dealt with promptly.
Retention, storage and destruction of clinical records
13.14 Records should be kept secure and confidential at all times and there should be adequate back-up in place if records are stored electronically.
13.15 The RCVS does not specify for how long clinical and client records should be retained and practices are free to set their own policies. Practices should however comply with any professional indemnity policy conditions relating to retention of records.
13.16 The record keeping requirements for Veterinary Medicinal Products (VMPs) are set out in the Veterinary Medicines Regulations (VMRs). Records of the retail supply (which includes administration) of POM-V and POM-VPS medicines must be kept for 5 years. The Veterinary Medicines Directorate provides specific guidance on record-keeping requirements for veterinary medicines.
13.17 Records should be destroyed in a manner which safeguards against accidental loss or disclosure of content and protects client confidentiality. (Client confidentiality)
13.18 Where a practice intends to cease trading, clients should, where possible, be notified so they have an opportunity to obtain a copy of relevant clinical and client records if they choose to do so. Likewise, provision should be made to respond to requests for other veterinary surgeons to take over the case.
Vaccination record cards
13.19 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.
13.20 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 21.30 – 21.33) should be followed. These state:
- 21.30 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.
- 21.31 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.
- 21.32 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.)
- 21.33 Where microchipping, tattooing or any other form of permanent identification has been applied it should be referred to in any certificate of identification.
13.21 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.