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Retention of medical records and diagnostic images

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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 maintained varies in different states and veterinarians must be aware of their local legal requirement.

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 X-rays can be released upon formal request to another veterinarian only with the authorisation of the client.

The Australian Small Animal Veterinary Association (ASAVA) Manual of Hospital Standards and Accreditation 2011 states that medical records must be kept long enough to comply with state and federal regulations and recommends 7 years.1

APPENDIX

State by State requirements as of April 2012.

This Appendix is included for information only and does not constitute a legal opinion on the minimum amount of time required to keep records.

NSW

The Regulations in NSW require a veterinarian to keep all records of any consultation, procedure or treatment for at least 3 years from when they were created (cl 15 (3)).

South Australia

In relation to how long the records should be kept, the Veterinary Practice Act 2003 does not specifically identify this. However, the Code of Professional Conduct is endorsed under the legislation and this recognises the need for records to be kept for at least 2 years after the relevant treatment/consultation. This period of time would be the minimum legal requirement under the SA Act.

However, the Board recommends that veterinarians keep medical records for a minimum of 7 years. Civil claims can be made within this timeframe and hence the recommendation from the Board. It also suggests the medical records are kept on the premises for 2 years and then transferred to an appropriate storage facility for the remaining 5 years.

Northern Territory

On the subject of maintenance and retention of veterinary medical records, the Code of Conduct prescribed in the Northern Territory Veterinarians Regulations, states as follows:

Code of Conduct – Prescribed in Schedule 2 of Veterinarians Regulations

Clause 4 (2) and (3) of the Code of Conduct include the following provisions on the maintenance of veterinary records:

Clause 4 (2)

A registered veterinarian shall keep case records in relation to each individual animal in his or her care and shall, unless parting with the record for the purposes of the provision of veterinary services by another person or at the written request of the owner, retain the record relating to an animal for a period of not less than 3 years beginning on the day on which he or she last examined or treated the animal.

Clause 4 (3)

Where records are provided at the written request of an owner in pursuance of subclause (2), the registered veterinarians shall obtain and retain a receipt signed by the owner in lieu of the record."

Western Australia

All practicing veterinary surgeons are professionally obligated to ensure they maintain appropriate clinical records. This obligation is not restricted to those instances in which scheduled drugs are prescribed or dispensed as detailed in Regulation 30 of the Veterinary Surgeons Regulations 1979, but applies to all professional services provided by veterinary surgeons to their clients.

Regulation 30 (3): The Registered veterinary surgeon must keep the clinical record for a period of 7 years.

Queensland

The statutory requirement is that case records must be kept by a veterinary surgeon for a minimum of 3 years from the day the last information about the animal is recorded.

As X-rays are a part of the case record, the Veterinary Surgeons Regulation provides that the records be kept for 3 years.

Tasmania

The Tasmanian Veterinary Surgeons Act 1987 at s34 requires that vets keep records for 7 years. The Act does not specify X-rays as such.

Veterinary Surgeons Act 1987 (No. 104 of 1987)

Requested: 6 March 2012

Consolidated as at: 6 March 2012

34. Records to be kept

  1. A veterinary services company, registered veterinary surgeon or registered veterinary specialist must -
    1. keep in a form and manner approved by the Board a record of -
      1. the name and address of each person for whom he, she or it provides a veterinary service;
      2. the nature of the service provided for that person;
      3. the date on which that service is provided;
      4. the identity of each registered veterinary surgeon or registered veterinary specialist who performed that service; and
      5. such other matters (if any) as the Board considers appropriate or as may be prescribed in the regulations for the purposes of this subsection; and
    2. preserve such a record for a period of 7 years.
Australian Capital Territory

The Health Professionals (ACT Veterinary Surgeons Board Standards Statements) Approval 2009 (No 1) states:

5.2.1 Records should be kept for at least seven years after the last occasion on which the animal received treatment.

Victoria

The Veterinary Practitioners Registration Board of Victoria has issued guidelines to assist registered Veterinary Practitioners in Victoria with respect to the minimum standard expected from them in their care and providing treatment to animals.

Guideline 11 deals with Veterinary Medical Records. Specifically Guideline 11.2.1 states:

“The length of time veterinary medical records must be kept is not stated in Law. Should legal action be brought against a registered veterinary practitioner, all documentary evidence would be brought to account. In that case it can be considered that veterinary medical records would be needed in defence. Records must be held for a minimum of three (3) years to comply with Drugs & Poisons legislation and should (for the purposes of defence) be held for at least six (6) years after the last occasion on which the animal received treatment.”

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

Date of ratification by AVA Board December 2013

Updated August 2015