List of items to include in a Medical Record – Georgia Rules

During the Leap presentations at the GVMA Fall Convention, I had several questions on what information needs to be included in a veterinary record.  The Georgia Board of Veterinary Medicine has given us a list in their Rules – Section 700-8-01 (c), Unprofessional Conduct. Please note that this is the list of what should be included, but is not limited to this information, as the Board rule specifies that information sufficient to justify the diagnosis and warrant treatment must be included, even if that information is not one of the items on this list. However, you *shall* have all of these items, according to the state board rules, which are referenced and empowered by the Veterinary Practice Act.  Take a look and see if it’s time to update or expand what’s in your medical records for clients…

(c) Failure to Maintain Patient Records:

1. A veterinarian shall prepare and maintain a record reflecting the care and treatment of animals treated.
. These records shall contain clinical information sufficient to justify the diagnosis and warrant treatment and shall, if applicable, include but not be limited to the following information:

(i) Name, address and telephone number of the animal’s owner;
(ii) Name of attending veterinarian and staff rendering care;
(iii) Patient identification, including name, ages, sex and breed;
(iv) Dates of examination, treatment and custody of the animal;
(v) Patient history;
(vi) Presenting complaint;
(vii) Vaccination history;
(viii) Findings from physical examination, including temperature and weight;
(ix) Clinical lab reports, if applicable;
(x) Medication and treatment, including frequency;
(xi) Anesthetic, including type and amount, if applicable;
(xii) Details of surgical procedure with complications and/or abnormalities noted, if    applicable;
(xiii) Progress and disposition of the case;
(xiv) Differential diagnoses; and
(xv) X-rays if applicable.

 

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