N.H. Admin. Code § Vet 701.01 - Daily Reports

(a) Every licensed veterinarian shall make daily written reports in the medical records of the animals he or she treats as follows:

(1) Records for companion animals and horses shall be kept for each animal, but records for livestock, as defined in RSA 21:34-a excluding horses, may be maintained on a group or client basis;

(2) The records shall be readily retrievable and shall be kept by the veterinary facility, practice owner, or licensed veterinarian medical director in the event that the veterinary practice owner is not a licensed veterinarian, for a period of at least 5 years following the last treatment or examination; and

(3) This record-making and keeping requirement in (1) and (2) above shall apply to any practice of veterinary medicine regardless of when, where, and how it was done or the reason the services were performed.

(b) The records required by Vet 701.01(a) shall include, but not be limited to, the following:

(1) Name, address, and telephone number of the animal's owner on each page of the medical record;

(2) Name, number, or other identification, such as microchip, tattoo, or ear tag, of the animal or group on each page of the medical record;

(3) Species, breed, age, sex, and color of the animal;

(4) Immunization record;

(5) Beginning and ending dates of custody of the animal;

(6) Date and time of visits and treatments;

(7) Reason for visit;

(8) An pertinent history of the animal's condition as it pertains to its medical status;

(9) Physical examination including:

(a) Whether within normal limits, abnormal, or not examined; and

(b) Absolute data as applicable, including, but not limited to:

a. Weight;

b. Temperature;

c. Heart rate; and

d. Respiratory rate;

(10) Laboratory, radiology and imaging, and ancillary services or data and interpretation;

(11) Assessment, prognosis, and provisional or final diagnosis;

(12) Plan for testing, diagnostics, and treatment;

(13) All treatments and medications administered, prescribed, or dispensed:

a. Including time, dose, and route of administration; and

b. Response to treatment;

(14) Surgery and anesthesia, including but not limited, to medications, materials, and vital signs;

(15) Progress of the case;

(16) Documented authorization by the client consenting to or declining of recommendations, and their associated risks, benefits, and costs;

(17) Cage charts, dental charts, surgical reports, and anesthesia monitoring records;

(18) All communications with clients whether in person, over the phone, in written or electronic form or via another method;

(19) An accurate description of dental procedures, including duration and identity of the practice team members involved in the procedure; and

(20) Discharge instructions.

(c) Computerized records shall be locked down every 24 hours so they shall not be altered.

(d) Medical records shall be legible.

(e) The author of medical record entries shall be permanently and uniquely identified, by code numbers or letters, initials, or signatures, in a manner that is understood by anyone examining such records.

(f) Sufficient information shall be entered in the history and examination portions of the record to justify the tentative diagnosis, problems, and treatment.

Notes

N.H. Admin. Code § Vet 701.01

#7418, eff 12-21-00; amd by #7710, eff 6-21-02, paras. (b)(c) EXPIRED: 12-21-08; ss by #9464-B, eff 4-23-09

Amended by Volume XXXIX Number 32, Filed August 8, 2019, Proposed by #12842, Effective 8/1/2019, Expires 1/28/2020. Amended by Volume XLII Number 41, Filed October 13, 2022, Proposed by #13454, Effective 9/28/2022, Expires 9/28/2032