Mich. Admin. Code R. 338.4921

Current through Vol. 24-21, December 1, 2024

Section R. 338.4921 - Medical records; requirements

Rule 21.

(1) A veterinarian who practices veterinary medicine in this state shall maintain a medical record for each animal patient, herd, flock, or other group of animals that accurately reflects the veterinarian's evaluation and treatment of the animal patient or group of animals rendered in person or through a telehealth service. Entries in the medical record must be made in a timely fashion.

(2) Records must be legible and retrievable. A record may be maintained in either a written, electronic, audio, or photographic format.

(3) A record for an individual animal patient, group, herd, flock, or other group of animals must document all of the following:

(a) Identification including, but not limited to, a tattoo, tag number, lot number, pen number, age, name, markings, sex, and species, as available.

(b) Date of the last veterinary service.

(c) Name, address, and telephone number of the client.

(d) Location of the animal patient or patients, if not at the location of the veterinary practice.

(e) Reason for the contact including, but not limited to, the case history, problem or signs of a problem, and whether the contact was a routine health visit or an emergency call.

(f) Vaccination history, if known.

(g) Results of the physical examination and a list of abnormal findings.

(h) Laboratory reports and other reports, if known.

(i) Diagnostic procedures utilized and the reports that pertain to these procedures.

(j) Procedures performed including, but not limited to, surgery and rectal palpations.

(k) Daily progress notes, if hospitalized.

(l) Informed consent, if appropriate.

(m) Diagnostic options and treatment plans.

(n) Any client communication deemed relevant.

(o) Prescribed medication.

(4) Records must be maintained for a minimum of 7 years from the date of the last veterinary service.

(5) Medical records are confidential and must not be released without the consent of the client or as required to protect public health or by law.

(6) Copies of complete medical records must be provided upon written or oral request from the client.

Mich. Admin. Code R. 338.4921

2011 AACS; 2016 AACS; 2021 AACS; 2023 MR 6, Eff. 3/22/2023