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§ 2032.3. Record Keeping; Records; Contents; Transfer.

16 CA ADC § 2032.3BARCLAYS OFFICIAL CALIFORNIA CODE OF REGULATIONS

Barclays Official California Code of Regulations Currentness
Title 16. Professional and Vocational Regulations
Division 20. Veterinary Medical Board
Article 4. Practice (Refs & Annos)
16 CCR § 2032.3
§ 2032.3. Record Keeping; Records; Contents; Transfer.
(a) Every veterinarian performing any act requiring a license pursuant to the provisions of Chapter 11, Division 2, of the code, upon any animal or group of animals shall prepare a legible, written or computer generated record concerning the animal or animals which shall contain the following information:
(1) Name or initials of the person responsible for entries.
(2) Name, address and phone number of the client.
(3) Name or identity of the animal, herd or flock.
(4) Except for herds or flocks, age, sex, breed, species, and color of the animal.
(5) Dates (beginning and ending) of custody of the animal, if applicable.
(6) A history or pertinent information as it pertains to each animal, herd, or flock's medical status.
(7) Data, including that obtained by instrumentation, from the physical examination.
(8) Treatment and intended treatment plan, including medications, dosages, route of administration, and frequency of use.
(9) Records for surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agents used, their route of administration, and their strength if available in more than one strength.
(10) Diagnosis or assessment prior to performing a treatment or procedure.
(11) If relevant, a prognosis of the animal's condition.
(12) All medications and treatments prescribed and dispensed, including strength, dosage, route of administration, quantity, and frequency of use.
(13) Daily progress, if relevant, and disposition of the case.
(b) Records shall be maintained for a minimum of three (3) years after the animal's last visit. A summary of an animal's medical records shall be made available to the client within five (5) days or sooner, depending if the animal is in critical condition, upon his or her request. The summary shall include:
(1) Name and address of client and animal.
(2) Age, sex, breed, species, and color of the animal.
(3) A history or pertinent information as it pertains to each animal's medical status.
(4) Data, including that obtained by instrumentation, from the physical examination.
(5) Treatment and intended treatment plan, including medications, their dosage and frequency of use.
(6) All medications and treatments prescribed and dispensed, including strength, dosage, route of administration, quantity, and frequency of use.
(7) Daily progress, if relevant, and disposition of the case.
(c)(1) Radiographs and digital images are the property of the veterinary facility that originally ordered them to be prepared. Radiographs or digital images shall be released to another veterinarian upon the request of another veterinarian who has the authorization of the client. Radiographs shall be returned to the veterinary facility which originally ordered them to be prepared within a reasonable time upon request. Radiographs originating at an emergency hospital shall become the property of the next attending veterinary facility upon receipt of said radiograph(s). Transfer of radiographs shall be documented in the medical record.
(2) Radiographs and digital images, except for intraoral radiographs, shall have a permanent identification legibly exposed in the radiograph or attached to the digital file, which shall include the following:
(A) The hospital or clinic name and/or the veterinarian's name,
(B) Client identification,
(C) Patient identification, and
(D) The date the radiograph was taken.
(3) Non-digital intraoral radiographs shall be inserted into sleeve containers and include information in subdivision (c)(2)(A)-(D). Digital images shall have identification criteria listed in subdivision (c)(2)(A)-(D) attached to the digital file.
(d) Laboratory data is the property of the veterinary facility which originally ordered it to be prepared, and a copy shall be released upon the request of the client.
(e) The client shall be provided with a legible copy of the medical record when the patient is released following emergency clinic service. The minimum information included in the medical record shall consist of the following:
(1) Physical examination findings
(2) Dosages and time of administration of medications
(3) Copies of diagnostic data or procedures
(4) All radiographs and digital images, for which the facility shall obtain a signed release when transferred
(5) Surgical summary
(6) Tentative diagnosis and prognosis, if known
(7) Any follow-up instructions.
Note: Authority cited: Section 4808, Business and Professions Code. Reference: Sections 4855 and 4856, Business and Professions Code.
HISTORY
1. Renumbering of former section 2031 to section 2032.3, including amendment of section heading and section, filed 5-25-2000; operative 6-24-2000 (Register 2000, No. 21).
2. Amendment filed 9-27-2013; operative 1-1-2014 (Register 2013, No. 39).
This database is current through 5/6/22 Register 2022, No. 18
16 CCR § 2032.3, 16 CA ADC § 2032.3
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