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Veterinary Clinical Record keeping Guidelines

Veterinary Clinical Record keeping Guidelines 2025

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The document is a comprehensive compilation of the Veterinary Surgeons Act 1960 and the Veterinary Surgeons Regulations 1979 as of July 26, 2019. It outlines the regulatory framework governing veterinary practice in Western Australia, including details on registration, professional conduct, the operation of veterinary clinics and hospitals, and the roles of veterinary surgeons and nurses. The document also includes provisions for licensing animal welfare societies and specifies fees associated with various applications and registrations.

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Click 'Get Form' to open the Veterinary Clinical Record keeping Guidelines in the editor.
Begin by entering the details of the veterinary clinic or hospital at the top of the form. This includes the name, address, and contact information.
Proceed to fill in the registration details. Ensure you provide accurate information regarding the managing veterinary surgeon, including their qualifications and registration number.
In the clinical record section, document any scheduled drugs prescribed or supplied. Include details such as animal identification, dosage, and administration instructions.
Review all entries for accuracy before saving your changes. Utilize our platform's features to highlight any important notes or reminders related to patient care.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

How many years should a veterinary practice store records?

Typically, states require veterinarians to keep records for three to five years after the most recent patient examination or treatment.

What information should be on a veterinary record?

(1)Name and address of client and animal. (2)Age, sex, breed, species and color of animal. (3)History or pertinent information as it pertains to each animals medial status. (4)Data, including that obtained by instrumentation, from physical examination.

What are the medical record policies of the AVMA?

The information within veterinary medical records is confidential. It must not be released except as required or allowed by law, or by client consent. A veterinarian is obligated to provide copies or summaries of medical records when requested by the client.

What is generally the most common information that veterinarians fail to include in the medical record?

Most common violations Some of the other issues we have encountered are the records are not legible; they do not include all treatment provided to the patient, medications/prescriptions and the dosages, or who is responsible for the care provided.

What should animal treatment and medical records include?

Animal Health Records Identity of the animal. Descriptions of any illness, injury, distress and/or behavioral abnormalities and the resolution of any noted problem. Dates, details and results of all medically related observations, examinations, tests and other such procedures.

Should I keep vet records?

Previous vet records are not required but always appreciated. Owners often misremember or forget details of their animals previous care, so having an objective record is optimal.

What should mortality records include for animals?

Mortality Record Sheet Date euthanized. Barn/Site. Cause of death. Type of humane euthanasia used. Check of death and insensibility. Person completing euthanasia.

What are pets medical records?

Your pets medical record is a confidential and legal record that systematically details their entire health history, just like your personal medical record. Its used to provide information, including the assessment, diagnosis, and treatment resulting from all of your pets veterinary visits.

Veterinary Clinical Record keeping Guidelines 2025

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