;

Retention of medical records and diagnostic images

Print

Ratification Date: 01 Aug 2015

Policy

Medical records and diagnostic images remain the property of the veterinarian or practice, not the client, and must be retained for legal reasons. The length of time these records should be retained varies in different jurisdictions, and veterinarians must be aware of their relevant state or territory requirement.

Similarly, the requirement to provide copies of records to clients varies by jurisdiction and if in doubt, advice should be sought from the relevant Veterinary Practitioners’ Board. If a copy of the report or image is requested, it should be provided at the client’s expense. If a copy is requested by someone other than the client, such as another veterinarian, the client’s written authority to provide such a copy to that third person should be obtained.

Background

It has been well established by legal precedents that medical records and diagnostic images (e.g. radiographs and ultrasound scan printouts) belong to the person or partnership creating them. All materials (e.g. X-ray film) purchased by the veterinarian also remain the property of the veterinarian, not the client.

The veterinarian is legally obliged to retain all records and images as part of his/her original medical records and to produce them in the event of a subpoena or other call for production of the records.

The client pays a fee for the generation of medical records and diagnostic images and is therefore entitled to be informed of the results and interpretations, and shown the report/image if they desire.

Case records and diagnostic images can be released upon formal request to another veterinarian only with the authorisation of the client.

The Australian Small Animal Veterinary group (ASAV) Manual of Hospital Standards and Accreditation 2019 states that medical records must be kept long enough to comply with state and federal regulations and recommends 7 years.1

References
  1. ASAV Manual of Hospital Standards. https://www.ava.com.au/asav/hospital-accreditation

Date of ratification by AVA Board December 2013. Technical update March 2023