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Rule Title: RECORD-KEEPING STANDARDS
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Department: LABOR AND INDUSTRY
Chapter: BOARD OF VETERINARY MEDICINE
Subchapter: General Provisions
 
Latest version of the adopted rule presented in Administrative Rules of Montana (ARM):

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24.225.410    RECORD-KEEPING STANDARDS

(1) The required standards of practice of veterinary medical record-keeping are as follows:

(a) Patient medical records, either written or electronic, shall be maintained for every animal accepted and treated as an individual patient by a veterinarian, and for every animal group (e.g., herd, litter, flock) treated by a veterinarian. These records shall be maintained and stored in an orderly manner lending itself to retrieval.

(b) When appropriate, licensees may substitute the words "herd," "flock," or other collective term in place of the word "patient" of this section. Records to be maintained on these animals may be kept in a daily log or in the billing records, provided that the treatment information that is entered is adequate to substantiate the identification of these animals and the medical care provided. In no case does this eliminate the requirement to maintain drug records as specified by state and federal law and board rules.

(c) The following data shall be clearly noted:

(i) name, address, and phone number of owner or agent;

(ii) description, sex (if readily determinable), breed, and age of or description of group;

(iii) date animal or group was seen, admitted, and discharged;

(iv) results of examination, condition, and diagnoses suspected;

(v) all medication, treatment, prescriptions, or prophylaxis given, including amount and frequency for both inpatient and outpatient care; and

(vi) diagnostic and laboratory tests or techniques utilized, and results of each.

(d) Veterinarians who practice with other veterinarians shall indicate by recognizable means on each patient's or animal group's medical record any treatment the licensee has performed, or which the licensee has directed support personnel to perform.

(e) All radiographs shall be permanently labeled to identify the veterinarian or premises, the patient, the owner, the date, and anatomical orientation.

(f) Medical records of both individual and group patients shall be maintained for a minimum of three years after the last visit.

(g) Consent forms, if used, should be part of the medical record.

(h) Veterinary medical records and images are the property of the practice and the practice owner. Information within veterinary medical records is privileged and confidential, and may not be released to anyone other than the owner of the patient, persons authorized by the owner, or other veterinarians involved with the treatment and care of the patient. Information must be released upon consent of the owner or authorized person(s). Consent may be in written, electronic, or other form of waiver, and must be documented in the patient's medical file. Confidentiality is waived under the conditions of (j).

(i) When requested by the owner, or person(s) authorized by the owner, as per (h), copies or summaries of the veterinary medical records and images must be provided within a reasonable time period, and as promptly as required by medical necessity. The veterinary practice may charge a reasonable fee for the preparation of summaries and copying of the records and images.

(j) Veterinary medical information may be disclosed without consent of the owner or person(s) authorized by the owner as follows:

(i) when required by court order or subpoena;

(ii) when the owner has made the veterinarian's care and treatment an issue in civil or criminal proceedings;

(iii) upon request for statistical or scientific research, as long as the information is abstracted and de-identified; or

(iv) upon request of public health officials, animal health officials, federal, state, or local officials, or agricultural authorities when it is deemed necessary to protect the welfare of the animal, and/or to protect public health and safety.

(k) A veterinarian who reasonably and in good faith reports or discloses records in accordance with (j) shall not be considered to be engaging in unprofessional conduct.

(l) A veterinarian may retain an animal or refuse to release records for failure to pay veterinary bills.

(m) A veterinarian practice owner terminating practice, retiring, relocating, or selling a practice shall notify clients within 30 days by local newspaper, in writing, or via other electronic means that they are no longer available to patients, and shall offer clients the opportunity to obtain a copy of their veterinary records, and shall specify who the new records owner is, when applicable, and where the medical records can be obtained. A failure to comply with this subsection may lead to disciplinary action.

(n) A veterinarian may not remove, copy, or use any part of any veterinary medical records without the express permission of the practice owner or as stated in (h).

(o) If a veterinarian, based upon his or her medical opinion, is willing to dispense medication, then the veterinarian must also provide a prescription in place of said medication should the owner request a prescription. If a veterinarian, based upon his or her medical opinion, is not willing to dispense medication, then the licensee should deny a request for a prescription.

History: 37-1-131, 37-1-319, 37-18-202, MCA; IMP, 37-1-131, 37-1-316, 37-1-319, MCA; NEW, 1999 MAR p. 1509, Eff. 7/2/99; TRANS, from Commerce, 2005 MAR p. 323; AMD, 2014 MAR p. 1092, Eff. 5/23/14.


 

 
MAR Notices Effective From Effective To History Notes
24-225-37 5/23/2014 Current History: 37-1-131, 37-1-319, 37-18-202, MCA; IMP, 37-1-131, 37-1-316, 37-1-319, MCA; NEW, 1999 MAR p. 1509, Eff. 7/2/99; TRANS, from Commerce, 2005 MAR p. 323; AMD, 2014 MAR p. 1092, Eff. 5/23/14.
7/2/1999 5/23/2014 History: 37-1-131, 37-1-319, 37-18-202, MCA; IMP, 37-1-131, 37-1-316, 37-1-319, MCA; NEW, 1999 MAR p. 1509, Eff. 7/2/99; TRANS, from Commerce, 2005 MAR p. 323.
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