The most frequently cited deficiency in a California Veterinary Medical Board (“VMB”) audit of a veterinary hospital is poor record-keeping.  The VMB takes the stance that if it’s not in the medical records, it didn’t happen.  Disciplinary action includes the denial, revocation, probation, or suspension of a license or a citation or fine. (Business and Professions Code section 4883(o).)
And the responsibility does not end with just Veterinarians.  Rather, as all Registered Veterinary Technicians (“RVT”) are responsible for knowing the laws governing their practice, and these laws include the California Veterinary Medicine Practice Act, RVTs are also responsible.  They, too, could be subject to discipline for a record-keeping violation.
Record-Keeping Regulation
The regulation regarding record-keeping is codified in the California Code of Regulations, Title 16, section 2032.3. This section states the minimum requirements of what must be included in a veterinarian’s records:

    1. Name or initials of the veterinarian responsible for entries.
    2. Name, address and phone number of the client.
    3. Name or identity of the animal, herd or flock.
    4. Except for herds or flocks, age, sex, breed, species, and color of the animal.
    5. Dates (beginning and ending) of custody of the animal, if applicable.
    6. A history or pertinent information as it pertains to each animal, herd, or flock’s medical status.
    7. Data, including that obtained by instrumentation, from the physical examination.
    8. Treatment and intended treatment plan, including medications, dosages and frequency of use.
    9. Records for surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agents used, their route of administration, and their strength if available in more than one strength.
    10. Diagnosis or tentative diagnosis at the beginning of custody of animal.
    11. If relevant, a prognosis of the animal’s condition.
    12. All medications and treatments prescribed and dispensed, including strength, dosage, quantity, and frequency.
    13. Daily progress, if relevant, and disposition of the case.

 
All records must be kept for a minimum of three (3) year’s after the animal’s last visit. (California Code of Regulation, section 2032.3(b).)  Upon a client’s request, a summary of the animal’s medical records must be made available and must include:

    1. Name and address of client and animal.
    2. Age, sex, breed, species, and color of the animal.
    3. A history or pertinent information as it pertains to each animal’s medical status.
    4. Data, including that obtained by instrumentation, from the physical examination.
    5. Treatment and intended treatment plan, including medications, their dosage and frequency of use.
    6. All medications and treatments prescribed and dispensed, including strength, dosage, quantity, and frequency.
    7. Daily progress, if relevant and disposition of the case.

 
Good Record-Keeping Protects and Serves Your Practice
California regulations are in place for very important reasons:

    • Written records establish what actually occurred.
    • Record-keeping protects the veterinarians and hospital should there be a negligence or malpractice suit, or complaint brought by an animal’s owner.
    • Good record-keeping allows an animal’s care to continue seamlessly should the animal have to go from one animal hospital to another.

 
However, by also absorbing some of the responsibility, an RVT is acting as a second set of eyes on the record of the animal.  This not only protects you and the veterinarian from discipline, but also ensures a thorough review of the progress of the animal.  It may also spur additional care or a review of the care already provided by the veterinarian and proactively address any complications or difficulties experienced by the animal from the care already provided. This may proactively address a small problem for the animal before it morphs in to a bigger problem.