13. Clinical and client records
Updated 24 April 2026
Clinical and client records
13.1 Veterinary surgeons and veterinary nurses must keep clear, accurate and adequately detailed records.
13.2 Clinical records include information about an animal’s health and medical care, and should provide a complete and relevant account of the animal’s clinical history, sufficient to support continuity of care. This includes details of any examination, treatments given, test results, proposed or ongoing plans for investigation, who has provided the care, and advice given to the client.
13.3 Client records include any information that relates to the person or entity engaging the services of the veterinary surgeon, including identifying details and financial information.
General principles
13.4 Clinical and client records should be:
a. Objective and factual.
b. Entered contemporaneously, or as soon as reasonably practicable after the event being recorded.
c. Legible and kept secure and confidential, either electronically or in hard copy.
d. Destroyed or deleted (where necessary) in a manner which protects client confidentiality and safeguards against accidental loss or disclosure of content.
13.5 Where a practice intends to cease trading, veterinary surgeons and veterinary nurses should, where possible, ensure clients are notified so they have an opportunity to obtain a copy of relevant clinical and/or client records.
Clinical records
13.6 Veterinary surgeons and veterinary nurses must provide copies of any relevant clinical records at the request of a client. They should obtain the client’s consent before sharing clinical histories that include personal data with another practice, unless the information is fully anonymised. Where clinical records include personal information of previous owners, the records should be anonymised before being sent.
13.7 Relevant clinical information should be provided promptly to any veterinary surgeon taking over responsibility for a case and appropriate documentation should be provided for all referral or re-directed cases. For further information, including on requesting clinical records in an emergency, see supporting guidance Chapter 5: Communication between professional colleagues.
13.8 Other than in exceptional cases, animal health, welfare and the public interest are best served when clinical records provided to clients or to veterinary surgeons assuming responsibility for a patient include the names of the veterinary surgeons and veterinary nurses who have provided care.
13.9 Clinical records may be amended to correct errors or factual inaccuracies, but there is no obligation to amend matters of clinical judgment or professional opinion solely at the request of the client. To maintain the audit trail, amendments should not remove or obscure the original entry. Amendments should also be dated, clearly show who made them, and, where possible, be recorded alongside the original entry.
13.10 Clinical records should be retained for as long as is necessary, taking into consideration legal and regulatory responsibilities, for example record keeping obligations for veterinary medicinal products. Veterinary surgeons and veterinary nurses may also wish to consider the terms of professional indemnity insurance policy conditions, which may specify minimum retention periods.
Client records
13.11 Client records will likely include personal data that is subject to regulation under the UK General Data Protection Regulation and the Data Protection Act 2018. These regulations must be complied with when controlling and processing personal data, and veterinary surgeons and veterinary nurses should be mindful that, among other things, clients have the right to access their own personal data via a subject access request. Guidance on the application of the legislation and a complete list of client’s rights in respect of their own personal data can be found on the Information Commissioner’s Office (ICO) website
13.12 Veterinary surgeons and veterinary nurses should avoid recording assumptions or subjective comments about a client. There may be a legitimate interest in documenting and retaining relevant factual observations to better inform colleagues about appropriate management of the client relationship. Where practicable, and in consideration of the guidance from the ICO, clients should be informed that this information has been recorded. Examples of such observations can include concerns relating to discrimination or violence against staff, or concerns relating to outstanding debts.
13.13 Veterinary surgeons and veterinary nurses should refer to the ICO for detailed information on the UK General Data Protection Regulation and the Data Protection Act 2018.