Mont. Admin. r. 24.225.514

Current through Register Vol. 23, December 6, 2024

Rule 24.225.514 - PATIENT MEDICAL RECORDS AND RECORDKEEPING

(1) Patient medical records shall be maintained for every animal accepted and treated by a veterinarian as:

(a) an individual patient; and

(b) every animal group (e.g., herd, litter, flock) .

(2) Patient medical records:

(a) must be maintained for a minimum of three years after the last visit by the patient;

(b) are the property of the practice and the practice owner where the records were prepared;

(c) must be legibly written;

(d) must be maintained and stored in an orderly, legible manner for easy retrieval by the veterinarian;

(e) must be safeguarded against loss, tampering, or use by unauthorized persons, readily available; and

(f) must contain sufficient information to permit any authorized veterinarian to proceed with the care and treatment of the patient by reading the medical record.

(3) In no case do the requirements in this rule eliminate the requirement to maintain drug records as specified by state and federal law and other rules in this chapter.

(4) Veterinarians may substitute the words "herd," "flock," or other collective term in place of the word "patient" when appropriate .

(5) Patient medical records may be kept in a daily log or in the billing records, provided the records meet the requirements of this rule .

(6) Patient medical records must include, but are not limited to the following:

(a) patient identification, including description, sex (if readily determinable), breed, and age;

(b) presenting complaint and relevant patient history;

(c) client identification, including name, address, and phone number;

(d) a record of every encounter and consultation regarding the patient;

(e) results of any part of a physical examination, including but not limited to weight, temperature, pulse, and respiration, and condition;

(f) all written records and notes, radiographs, sonographic images, video recordings, photographs, or other imaging and laboratory reports;

(g) treatments or intended treatment plans, or both, including:

(i) medications; and

(ii) amounts of medications administered, dispensed, or prescribed including amount and frequency for both inpatient and outpatient care;

(h) diagnosis or tentative diagnosis, including diagnostic and laboratory tests or techniques utilized, and the results of each;

(i) when pertinent, a prognosis; and

(j) any authorizations, details of conversations, releases, waivers, discharge instructions, or other related documents.

(7) Veterinarians shall indicate by recognizable means on each patient's medical record any treatment the licensee has performed, or which the veterinarian has directed support personnel to perform.

(8) All radiographs referenced in (6) shall be permanently labeled to identify:

(a) the veterinarian or business name of the practice;

(b) the patient;

(c) the owner;

(d) date the radiograph was taken; and

(e) anatomical orientation of the radiograph.

(9) Information within patient medical records is privileged and confidential, and may not be released to anyone except the following:

(a) owner of the patient;

(b) persons authorized by the owner;

(c) other veterinarians involved with the treatment and care of the patient; or

(d) as required by (12).

(10) Information within patient medical records must be released upon consent of the owner or authorized person(s). Consent may be in written, electronic, or other form of waiver, and must be documented in the patient's medical record. Confidentiality is waived under the conditions of (12).

(11) When requested by the owner or person(s) authorized by the owner as per (9), copies or summaries of the veterinary medical records and images must be provided by the veterinarian within a reasonable time period and as promptly as required by medical necessity. The veterinary practice may charge a reasonable fee for the preparation of summaries and copying of the records and images.

(12) Veterinary medical information may be disclosed without consent of the owner or person(s) authorized by the owner as follows:

(a) when required by court order or subpoena;

(b) when the owner has made the veterinarian's care and treatment an issue in civil or criminal proceedings;

(c) upon request for statistical or scientific research, as long as the information is abstracted and de-identified;

(d) upon request of public health officials, animal health officials, federal, state, or local officials, or agricultural authorities when it is deemed necessary to protect the welfare of the animal, and/or to protect public health and safety; or

(e) in response to a complaint filed with the board.

(13) A veterinarian may retain an animal or refuse to release records for failure to pay veterinary bills.

(14) A veterinarian-practice owner terminating practice, retiring, relocating, or selling a practice shall:

(a) notify clients within 30 days by local newspaper, in writing, or via other electronic means that they are no longer available to patients;

(b) offer clients the opportunity to obtain a copy of their veterinary records;and

(c) specify who the new records owner is, and when applicable, where the patient medical records can be obtained. Failure to comply with this subsection may lead to disciplinary action.

(15) A veterinarian may not remove, copy, or use any part of any patient medical records without the express permission of the practice owner or per (9) and (10).

(16) If a veterinarian, based upon the veterinarian's medical opinion, is willing to dispense medication the veterinarian must also provide a prescription in place of said medication should the owner request a prescription.

Mont. Admin. r. 24.225.514

Transfer from 24.225.410,2018 MAR p. 1281, Eff.7/7/2018; AMD,2020 MAR p. 1633, Eff.8/29/2020

AUTH: 37-1-131, 37-1-319, MCA IMP: 37-1-131, 37-1-316, 37-1-319, MCA