Mich. Admin. Code R. 338.4921 - Medical records; requirements
Rule 21.
(1) A
veterinarian who practices veterinary medicine in this state shall maintain a
medical record for each animal patient, herd, flock, or other group of animals
that accurately reflects the veterinarian's evaluation and treatment of the
animal patient or group of animals rendered in person or through a telehealth
service. Entries in the medical record must be made in a timely
fashion.
(2) Records must be legible
and retrievable. A record may be maintained in either a written, electronic,
audio, or photographic format.
(3) A
record for an individual animal patient, group, herd, flock, or other group of
animals must document all of the following:
(a) Identification including, but not limited
to, a tattoo, tag number, lot number, pen number, age, name, markings, sex, and
species, as available.
(b) Date of
the last veterinary service.
(c)
Name, address, and telephone number of the client.
(d) Location of the animal patient or
patients, if not at the location of the veterinary practice.
(e) Reason for the contact including, but not
limited to, the case history, problem or signs of a problem, and whether the
contact was a routine health visit or an emergency call.
(f) Vaccination history, if known.
(g) Results of the physical examination and a
list of abnormal findings.
(h)
Laboratory reports and other reports, if known.
(i) Diagnostic procedures utilized and the
reports that pertain to these procedures.
(j) Procedures performed including, but not
limited to, surgery and rectal palpations.
(k) Daily progress notes, if
hospitalized.
(l) Informed consent,
if appropriate.
(m) Diagnostic
options and treatment plans.
(n)
Any client communication deemed relevant.
(o) Prescribed medication.
(4) Records must be maintained for
a minimum of 7 years from the date of the last veterinary service.
(5) Medical records are confidential and must
not be released without the consent of the client or as required to protect
public health or by law.
(6) Copies
of complete medical records must be provided upon written or oral request from
the client.
Notes
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