What paper can I use with prescription pads for DEA controlled substances

This is a common question I get when doing records management training. It is often accompanied by the inevitable… can I use an e-mail for a prescription?  Once again, the answer is on our helpful DEA guide at https://www.deadiversion.usdoj.gov/pubs/manuals/pract/pract_manual012508.pdf.  The answer is that the DEA *recommends* “7. Use tamper-resistant prescription pads. ”

But what does “tamper resistant” mean?  Good news, CMS (“the Centers for Medicare & Medicaid Services”) has issued guidance to the States on what in the world a tamper-resistant pad is….  a prescription pad must contain:

  1. One or more industry-recognized features designed to prevent unauthorized copying of a completed or blank prescription form;
  2. One or more industry-recognized features designed to prevent the erasure or modification of information written on the prescription by the prescriber; or,
  3. One or more industry-recognized features designed to prevent the use of counterfeit prescription forms.

Now the CMS does not govern veterinary medicine, but I’d rely on the DEA treating this as analogous, since they use the same term and govern both human and veterinary prescriptions of controlled substances.

There’s no particular brand or type required, but you should focus on the ability through fraud, theft, or collusion to create an unauthorized prescription in your name or with your number. Just because a vendor or on-line site says their prescription pad is “tamper-resistant”, I wouldn’t trust them. I read the description and determine if the above three criteria are met.

Also, a computer generated prescription, on tamper proof prescription paper, may meet the requirements above. Don’t just use the paper you get from staples if you are taking this route, and even if you do, you still have to sign it.

Also, make sure the pad has room for the following information, as specified in the manual on page 30.

“Each prescription must indicate the full name and address of the patient, the drug name, strength, dosage form, quantity prescribed, directions for use and the name, address, and DEA number of the practitioner.”

It should have a place for signature, as well as the date of the signature.

Lastly, we have to remember to get it right, since you shouldn’t be able to erase or modify. I think it’s best to destroy the prescription, make a record of it, and then create a new one if you make a mistake when writing it.

So, until the next time, let’s get better together!

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What can DVMs do at my practice before they are licensed?

You’re hiring a recent graduate, and you want to put them to work as soon as possible. What can they do? Essentially you’ll need a temporary license, and they have to be supervised. If the results show they failed the exam, the temporary license ends. There’s a lot more to it, and exceptions abound. As a result, I thought it easier just to quote the relevant sections. As in all of my quotes, laws and rules change, so it’s best to look at the source material when possible.

If you are not in Georgia, your practice act hopefully follows the AVMA Model Practice Act, which in section 12 states that they can issue a temporary permit,to practice when they are under indirect supervision of a licensed veterinarian.

AVMA Model Practice Act – Section 12 – Temporary Permit

The Board, in its sole discretion, may issue a temporary permit to practice veterinary medicine in the State:

  1. To a qualified applicant for license, pending examination, provided that such temporary permit shall expire the day after the notice of results of the first examination given after the permit is issued and provided that the grantee is under indirect supervision of a licensed veterinarian. No temporary permit may be issued to any applicant who has previously failed the examination in the State or in any other state, territory, or district of the United States or a foreign country.

A temporary permit may be summarily revoked or limited by the Board without a hearing.


In Georgia, under OCGA 43-50-30, only the board can grant a temporary license. The practice act states that: “(a) No person may practice veterinary medicine in this state who is not a licensed veterinarian or the holder of a valid temporary license issued by the division director pursuant to this article.”

 Section 43-50-42 covers how that works…I’ve quoted the key portions below:

(a) The board may issue a temporary license to the following applicants who are qualified to take the veterinary license examination:

(1) An applicant licensed in another state. Such license shall have the same force and effect as a permanent license until the time of its expiration; and

(2) An applicant who is not the holder of any veterinary license. Such license shall authorize the applicant to work under the supervision of a licensed veterinarian as provided by the board.

(b) The temporary license shall expire on the date that permanent licenses are issued to persons who have passed the examination provided for in Code Section 43-50-32, which examination occurred immediately following the issuance of the temporary license.

(c) A temporary license issued pursuant to this Code section may, in the discretion of the board, be renewed for one six-month period only; provided, however, that no temporary license shall be issued, renewed, or reissued to a person who fails to pass the examination established by the board.

If this didn’t answer your excellent GVMA Fall Convention questions, please message me and I’ll provide additional answers.

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Risky Testimonials, Advertising Restrictions

Veterinarians need to be very careful before providing an endorsement or testimonial for a product or medicine. It has to be truthful, it has to give the context to avoid being misleading, and in many cases, it violates laws or even the practice act. This was a hot topic, which lead veterinarians at the GVMA to ask “should I ever give a vendor a testimonial?” And based on my answer, which is “only in the very limited circumstance, where it is truthful, not misleading or deceptive, used only in a non-commercial setting, and has proper context to avoid material omissions or false impressions…” I recieved some calls from pharmaceutical vendors asking about why I’d said that.  Luckily my presentation quoted the updated Board of Veterinary Medicine rules, and I discussed some of the ethical constraints under the AVMA code of ethics (in some of my presentations). I can only imagine the volume of calls to veterinary medical company legal departments after my CEs.

For me, it makes sense that there would be restrictions on testimonials in a commercial setting. This is not the same as a clinical/educational setting where peer reviewed studies and practical application of veterinary medicine may involve discussing the protocols and products a particular vet uses.

I try to remember that most boards of veterinary medicine and practice acts are designed to protect the public from unprincipled, dishonest, and incompetent veterinarians. The last thing they want is some client in the exam room saying “I know you recommend this, but I saw Dr. Sheila say that this other medication is better… you need to give me that one.” Now, out of context, without any knowledge of the case, the opinion of a vet without a VCP or exam of the animal is being injected into another professional’s practice of veterinary medicine. Even if it isn’t said, our reputation will now be judged and discussed based on whether we agree with another vet’s endorsement, rather than the quality of our application of medical judgement for the best prescription for that case.

Georgia Rule 700-8-01.b.3 states “It shall be unprofessional conduct for a licensee or registrant to guarantee a cure or to offer his name in a commercial setting in a testimonial as to virtues of proprietary remedies or foods.”

That’s pretty clear to me that  in Georgia, vets shouldn’t praise the quality or results of a remedy. Human medical practicioners have similar rules about avoiding even implications of a guaranteed outcome or endorsing a medication.

But even we weren’t in the State of Georgia, we’d have to be very careful about providing a testimonial. Once we provide it, we typically do not have future control on the testimonal’s use. What happens if the marketing department of the vendor takes only a part of our testimonial, out of context? What if it’s placed with other content that leaves a false impression, or creates a broader positive statement than we intended?  Unless we have final approval rights on the form, substance, and context of the the testimonial, my clinic veterinarians may be engaging in false, deceptive, or misleading statements in advertising.

The AVMA code of ethics, Section III, K  states that:

“Advertising by veterinarians is ethical when there are no false, deceptive, or misleading statements or claims. A false, deceptive, or misleading statement or claim is one which communicates false information or is intended, through a material omission, to leave a false impression.

Testimonials or endorsements are advertising, and they should comply with applicable law and guidelines, such as the Federal Trade Commission guide and regulations relating to testimonials, endorsements, and other forms of advertising.”

For clarity, the FTC prohibits false or misleading advertising with consumers, and can impose significant fines on parties that engage in this behavior. It might not only be a cause for the board to discipline us for unprofessional conduct, it has the potential  of the FTC to fine not only the veterinary medicine supplier, but the testimonial providing vet as well. I can’t evaluate how big that risk might be, but since ethically we can’t receive payment to endorse a particular vendor’s product, I’d say the risk isn’t worth the gain in most cases.

Now, if  one of our vets wants to stand up in a Continuing Education or clinical setting and talk about what they use and the results they’ve seen, or publish a learned article on the topic in a medical journal, or post a reply on a forum online that’s not public, then there may be some more room to ‘testify’ about a product. But if  that CE is sponsored by a vendor and they are taking orders at the door, that’s still a significant risk of it being interpreted as a commercial setting… to me. If it’s just vets and their colleagues talking about protocols, it may be perfectly acceptable. Context makes a world of difference.

Regardless of what we decide to do,  I recommend that vets in any practice make certain before they do that quote for their favorite vendor, the vets look at your practice act, rules, and the ethical code… and feel comfortable that they aren’t violating them in spirit or word.

That’s one way that we can all have better vet practices.

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Upcoming Blog Topics from GVMA Fall Convention

The GVMA Fall Convention was fantastic. We had three sessions, with over 50 people per session, sometimes standing room only with overflow in the hallways. There was lots of excellent dialogue and practical questions.  I offered to answer a few difficult ones on this blog, so over the next three  to five days you should get answers on:

  1. Can I provide a testimonial or quote to a vendor for their product? [Posted 11-8-16]
  2. What are the limitations on using a vet after the exams but before their license is granted? [Posted 11-9-16]
  3. What are the types of paper for prescriptions that we should use?
  4. What are the types of logging for DEA Scheduled drugs we should use?
  5. Which owner has a right to the records?

I have already had reports of vets using the information gained in the sessions to protect their licenses and practice according to the practice act. It’s inspiring to see attendees reflect upon, and integrate, some of the guidance from leap sessions into their practices.

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At the GVMA Fall Convention in Atlanta

I’m at the fall GVMA Convention in Atlanta this weekend. Tomorrow I’ll be presenting three two hour Law, Ethics, and Professionalism continuing education sessions for a select group of Georgia Veterinarians. I’ve already received a number of questions on advertising, client relationships, and record keeping. All of these will be answered at the LEAP training, and I’ll follow-up with new questions on this blog. Most exciting will be the record keeping session, where vets will get a chance to make their own record management plan for their practice(s).

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How many vet techs can be at a clinic?

You’d think the answer is easy… but it’s not. In some cases it requires some interesting math and definitional choices. And in a recent leap in Columbus, GA, I answered a question.. if not completely wrong, mostly so. I said “four vet techs per practice maximum, which is not even remotely correct.” Thank goodness I have this blog to post my errors and failings to the world!

The answer is that it is based upon the ratio of vets to vet techs, as well as whether your practice includes certified specialists. It is a variable number that involves math, never a lawyer’s strong suit. For our clinic, with two full time vets and two part time vets… I think the answer is either 4 vet techs or 8, depending upon whether regular practice of veterinary medicine includes vets that work less than 40 hours a week.

So here we go with my more comprehensive, but still confused answer:

First, there can be no more than four vet techs under the supervision of 1 veterinarian at any one time.

OCC 43-50-55 (c)(1) “No licensed veterinarian shall have more than four veterinary technicians on duty under his or her supervision at any one time.”

But, that’s not all folks… You cannot have more than 2 techs for every regular vet working at your clinic. So to have four veterinary technicians under one vet, you need to have at least 2 regular (not relief) vets in your practice.

OCC 43-50-55 (c) (2) No licensed veterinarian shall practice veterinary medicine at a veterinary facility when the number of veterinary technicians employed at such veterinary facility exceeds the number of licensed veterinarians regularly engaged in the practice of veterinary medicine at such veterinary facility by a ratio of more than 2:1.

Now if you are a specialty clinic, you can have 5 vet techs per vet…

OCC 43-50-55 (c) (3) The provisions of paragraphs (1) and (2) of this subsection shall not apply to any licensed veterinarian engaged in a specialty practice if he or she is certified for such specialty practice by a college approved for such purpose by the American Veterinary Medical Association or its successor organization; provided, however, that no such licensed veterinarian shall engage in such specialty practice at a veterinary facility when the number of veterinary technicians employed at such veterinary facility exceeds the number of licensed veterinarians regularly engaged in a specialty practice of veterinary medicine at such veterinary facility by a ratio of more than 5:1.

Secondly, under the statute, there is a clear requirement that to be a specialty practice, you need a certification from a college approved for the certification from the AVMA.

This brings up some weird math problems… such as… if you have six veterinarians that are not engaged in a specialty practice, and one that is… how many techs can you have at the practice?  Is it 3*2 (regular) = 6 techs  + 5 techs (specialty) = 11 techs… or is it the higher of 6 or 5 techs = 6 techs?

And what exactly is “regularly engaged in the practice of veterinary medicine?” Does 20 hours a week work? 30 hours? 10 hours?

Let me know your thoughts on this, it’s unclear to me.. I think I am stumped.

Until next time, let’s get better together.

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Legal Form:”I’m the owner”

Sometimes you can get into a pickle where the microchip or your records show a different owner, but the animal needs care. Here’s a clause we include in our intake forms and used to have separately to cover this issue. There’s been a number of articles on this in DVM360, the Georgia Veterinarian, and I’ve authored a few myself (including on this blog). The clause below works for me, and if you’re updating your forms with a local attorney, showing her this may help save you some time and expense. As with all forms, they do not work for all situations and I recommend seeking legal counsel when in doubt.

Sample clause-

I, _______________, hereby certify that I am the rightful owner/caretaker of [Animal Name] and have full title and/or authority for [ Animal Name]. I authorize [Veterinarian] to treat [Animal Name] and shall be responsible for payment of such charges that are reasonably related to such treatment and are authorized by me. Even in the event that title or ownership of [Animal Name] is disputed or transferred, I shall pay and remain responsible for such charges, up until the time I inform you in writing otherwise.


Certified by  __________

Signed on [Date] ___________

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What is expected by my clients when we vaccinate their pet? (Part 1)

Many clinics bring in a client, have an assistant pop some shots, and send off the client without the patient being seen or examined by a vet. The only records in the record management system is that a shot was delivered on a certain date, perhaps with the charges noted. This is particularly common in some of the mobile vaccination clinics. Is it ok for a dog to receive vaccines without interaction with a veterinarian?

Well, the answer is yes, in some circumstances. An owner can buy vaccines and administer them by themselves. We all know of some farm supply or pet supply companies that provide vaccines directly to the consumer.  And if there’s an adverse reaction or the vaccine isn’t administered correctly, the owner is taking the risk themselves.

But when an owner comes to a vet clinic, mobile or not, it’s my opinion that they have certain reasonable expectations.  They expect that the vaccine will be administered properly. They expect that it has been stored properly and is active. They expect that if there is an adverse reaction, the veterinarians of that clinic will be there to help them. They expect that the vet/clinic will inform them if there are risks with taking a vaccine, depending upon the breed, age, and health condition of the patient. And if any of these things do not happen, they rely upon some government agency to monitor, set standards, and require those providing the shots to conform to these expectations.

That’s not my legal analysis, just my experience with customers who have complained about vaccinations at vet clinics or stores.   So I recommend that all your staff, particularly assistants, are trained to:

  1. Explain how the vaccines are stored and protected.
  2. Explain the typical risks of vaccines, and offer to have a vet discuss those risks with the owner.
  3. Explain what to do if there is an adverse reaction, and how they can tell if their pet is having an adverse reaction.
  4. Train staff in how to properly administer vaccines, and when not to administer the vaccine (some states require vets to perform rabies vaccines, for example).
  5. Set up consistent protocols for vaccines.
  6. Keep detailed records of when vaccines are given, along with the general health of the animal.
  7.  Have staff ready to explain what advantages having a vet clinic administer vaccines provides. Some vaccine providers have additional warranties and remedies for the vaccines, including payment of care in the event of an adverse reaction, or a failure of the vaccine with records of proper compliance.

In some states, an exam may be required to create the veterinary-patient-owner relationship. We’ll talk about that, along with other legal requirements, in part two.




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Protect your Vaccines!

Our clinic had a power outage a few years ago and thousands of dollars of vaccines were lost as a result. Georgia is HOT, and not only were the vaccines ruined, but we had to reschedule appointments until the new replacement vaccines we ordered came in.  I’d highly recommend a few steps we now have in place, to avoid this type of fiscal and customer nightmare.

First, make certain your fridge is relatively new. When we got our clinic, we had a stainless steel enameled fridge from the 70s. It could protect from a Soviet blast, but wasn’t reliable at keeping temps.  We now have a relatively new fridge and plan on replacing it every few years.

Second, use a separate fridge for vaccines from food, samples, and other items. The fewer times the door opens, the easier it is to maintain the temperature.

Third, get a surge protector on it. A few lightning strikes or shifts in power can fry your fridge.

Those top three are what most clinics we know do. But I’ve got another step that we’re taking, because spending $200 to avoid $5000 in losses seems like a good idea to me. Your mileage may vary.

We bought an APC uninterruptable power supply. (Liebert makes good ones too). It’s not fancy, here’s a link to it, though I am not endorsing any particular model or brand. https://www.amazon.com/APC-BG500-Back-UPS-Pro-500/dp/B00DW2J7SY

This sends out an annoying alarm when power is out. It keeps the fridge running for about 15 minutes. But that’s plenty of time for someone to hear and respond to the alarm.

It also sends out an e-mail-text when connected to your network.  Now, if your power is out in your clinic, then your network will likely also be down.  BUT, we have a similar unit on our network, so that when the power goes out, the network stays on long enough to for the fridge to tell us it lost power.

And if the power is out, I want the clinic manager, kennel manager, and key staff to know. They are all on the alert e-mail list.

These alerts and alarms give us the time to get to the clinic and move vaccines to a yeti to transport somewhere we have power, or to get the generator up. I have no illusions that Georgia Power will divert resources in an outage for my vaccines, but I have a back-up plan until they do.

Some people buy insurance to cover power outages, and just absorb the deductable. As you can tell, I think there’s an easy and cost effective way, that’s far less than a deductable to protect your inventory and investment, and to make certain your clients aren’t inconvenienced by having to reschedule for another day when you will have vaccines.

So, while we probably should do 1-3, setting up UPS alerts and messages is really a matter of risk appetite and customer focus.

Next up I’ll be discussing the administering of vaccines, starting in part 1 with staff training, education, and customer expectations.

Let’s get better together!


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