Section 195. Recordkeeping

A. A daily record of each patient treated shall be maintained by the veterinarian at the permitted veterinary establishment and shall include pertinent medical data such as drugs administered, dispensed or prescribed, and all relevant medical and surgical procedures performed. Records should contain at a minimum:

1. Presenting complaint/reason for contact;

2. Physical examination findings, if appropriate;

3. Tests performed and results;

4. Procedures performed/treatment given and results; and

5. Drugs (and their dosages) administered, dispensed or prescribed.

B. Individual records shall be maintained on each patient, except that records for economic animals or litters of companion animals under the age of four months may be maintained on a per client basis. Client records shall be kept for a period of three years following the last office visit or discharge of such animal from a veterinary establishment.

C. An animal identification system must be used by the establishment.

D. Upon the sale or closure of a veterinary establishment involving the transfer of patient records to another location, the veterinarian shall follow the requirements for transfer of patient records in accordance with § 54.1-2405 of the Code of Virginia.

E. An initial rabies certification for an animal receiving a primary rabies vaccination shall clearly display the following information: "An animal is not considered immunized for at least 28 days after the initial or primary vaccination is administered."

Historical Notes

Derived from Volume 15, Issue 05, eff. December 23, 1998; amended, Virginia Register Volume 19, Issue 09, eff. March 1, 2003; Volume 21, Issue 23, eff. October 8, 2005; Volume 26, Issue 04, eff. November 25, 2009.

Statutory Authority

§ 54.1-2400 of the Code of Virginia.