Iowa Code r. 811-12.4 - Veterinary medical records
(1)
Controlled substances records. The licensed veterinarian must
maintain a controlled substance log that contains complete, accurate and
readily retrievable records of all controlled substances possessed,
administered or dispensed.
a. Each record of a
controlled substance that is dispensed must meet all U.S. Drug Enforcement
Administration and Iowa board of pharmacy regulations for the controlled
substances log.
b. Each log record
must include the following information:
(1)
Name or identification of the patient.
(2) Client's name and address, if not readily
available from the licensed veterinarian's records.
(3) Name, strength and quantity of the
controlled substance dispensed.
(4)
Date on which the controlled substance was dispensed.
(5) Initials of the dispensing licensed
veterinarian or authorized auxiliary.
(6) Name of the prescribing licensed
veterinarian.
c. All
controlled substances must be kept in a locked storage area, and access to the
storage area must be limited pursuant to state and federal laws and
regulations.
d. Each package or
container in which a controlled substance is stored or dispensed must be
clearly labeled pursuant to the requirements set forth in state and federal
laws and regulations.
e. Each
package or container in which a controlled substance is stored or dispensed
must comply with all state and federal packaging requirements and with rule
811-12.2 (169).
(2)
Patient records. Patient records are the property of the
veterinary practice. Each licensed veterinarian shall maintain for at least
five years an easily retrievable record for each patient that receives
veterinary services. The record must be available for inspection by the client
during normal business hours. The information within patient records is
privileged and confidential and cannot be released except by court order, a
public health emergency, consent of the client or as otherwise authorized by
law. The licensed veterinarian in charge shall provide a copy of the complete
record to the client not later than two business days after the licensed
veterinarian or practice receives from the client a request for the record. A
licensed veterinarian or veterinary practice may have an additional three
business days to provide a copy of nondigital diagnostic images. The licensed
veterinarian may charge reasonable and customary fees for the copying of
records.
a. Records required for patients
defined as "livestock" in Iowa Code section 717.1(4) include the following:
(1) Name, address and telephone number of the
client.
(2) Name or identity of the
patient, pen, herd, flock or group, including the identification number, if
any.
(3) Date of service.
(4) Documentation of client
consent.
(5) Diagnosis or condition
at the beginning of treatment of the patient, including results of
tests.
(6)
Procedures/indications.
(7) Name of
drug or medication and treatment administered indicating dosage, frequency and
route of administration.
(8)
Withdrawal period.
(9) Record of
diagnostic images taken.
(10) Name
of attending licensed veterinarian.
b. Records required for other patients
include the following:
(1) Name, address and
telephone number of the client.
(2)
Name and identity of the patient, including the identification number, if
any.
(3) Date of birth (or
estimated age), sex, species and breed of patient.
(4) Dates of care, custody or treatment of
the patient.
(5) A history of the
patient's condition as it pertains to the patient's medical status.
(6) Documentation of client
consent.
(7) Diagnosis or condition
at the beginning of treatment of the patient, including results of tests and
body weight.
(8) Surgery record,
including preanesthesia medication, anesthesia and the procedure
performed.
(9) Name of drug or
medication and treatment administered indicating dosage, frequency and route of
administration.
(10) Progress and
disposition of the case.
(11)
Record of diagnostic images taken.
(12) Name of attending licensed
veterinarian.
(3)
Stored diagnostic
images.
a. Each stored diagnostic
image must be identified with the following information:
(1) The name of the licensed veterinarian or
facility that took the diagnostic image.
(2) The name or identifying number, or both,
of the patient.
(3) The name of the
client.
(4) The date on which the
diagnostic image was taken.
(5) The
anatomical orientation depicted by the diagnostic image.
b. Stored diagnostic images must be retained
for at least five years.
c. A
stored diagnostic image of the patient or a copy must be released, upon the
written or verbal request, to another licensed veterinarian who has the
authorization of the client. Original diagnostic images shall be returned in a
reasonable time.
(4)
General anesthesia. General anesthesia is a condition caused
by the administration of a drug or combination of drugs sufficient to produce a
state of unconsciousness or dissociation and blocked response to a given pain
or alarming stimulus. The following standards relating to general anesthesia
apply:
a. Within 12 hours prior to the
administration of a general anesthetic, the patient must receive a physical
examination, with the results noted in the patient's medical records.
b. The patient under general anesthesia must
be under observation for a length of time appropriate to the species for the
patient's safe recovery.
c. The
licensed veterinarian must provide a method of respiratory monitoring that may
include observing the patient's chest movements, observing the rebreathing bag
or using a respirometer.
d. The
licensed veterinarian must provide a method of cardiac monitoring, which may
include the use of a stethoscope or electrocardiograph monitor.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
No prior version found.