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Records - Confidentiality
Ownership of case records
Ownership of radiographs
Providing case records to another veterinarian
Specialist referral procedure
The meaning of the term veterinary science as defined in the Veterinary Surgeons Act includes signing or issuing certificates relating to the description, health, diagnosis or treatment of animals.
The Boards policy is that vaccination certificates must include the practice's name, owner's name, animal's description, type of vaccine, date of vaccination and follow up instructions. The Board does not make any ruling on the form that vaccination certificates should take provided these requirements are met.
It is considered professional misconduct for a veterinarian to sign or issue in a professional capacity any certificate, notice, report or like document that is incomplete or is false or misleading in a material respect.
Giving incomplete and unsigned veterinary certificates to pet shops, breeders or practice clients for completion by the owner at time of sale of an animal is not acceptable.
Veterinary certificates, whether manually or computer generated, must be signed exclusively by registered veterinarians. Lay staff should not be put in a position where they could be prosecuted in a civil court for a breach of the Veterinary Surgeons Act.
NOTE: Vaccination certificates signed by lay persons e.g. breeders, are not veterinary certificates. Nothing prevents a non-authorised person from vaccinating animals prior to sale with a Schedule 5 product (killed vaccine) however a certificate relating to the description, health, diagnosis or treatment of animals can only be signed and issued by a veterinarian. Schedule 4 vaccines (live vaccines) can only be administered or dispensed by registered veterinarians.
The statutory requirement is that veterinarians must keep their client records for a period of at least three years from the date of the last examination or procedure. Veterinarians can make copies of records to a client concerned with the consent of the managing veterinarian but there is no legal requirement to do so (refer to the following article – Ownership of Case Records).
The meaning of the term ‘professional misconduct’ is not limited in the Veterinary Surgeons Act and nothing prevents initiation of misconduct proceedings in the event of lodgement of a complaint by a person aggrieved by the actions of a veterinarian in releasing personal information to a third party.
The Board believes the guideline documented in the AVA Code of Professional Conduct is the benchmark that should be applied in respect to confidentiality of records.
The AVA Code of Conduct reads:
Veterinarians must consider as confidential any information concerning an animal under their care derived from either the owner or someone acting on the owner’s behalf or from examination of the animal. They should not divulge such information to any third party except with the owner’s consent, or where there is an obligation to do so under the law. The opinion that the public welfare is endangered outweighs the primary obligation to the owner, e.g. if presented with an animal that is believed to have been imported into the country without all due observance of quarantine requirements, or an animal with a notifiable disease. The foregoing is not to be taken as prohibiting the communication of information to professional colleagues and lay staff properly involved in the animal’s care, or to students receiving instruction in relation to the animal. In such circumstances, however, the veterinarian concerned should ensure that the lay staff and students are made fully aware of the ethical obligations involved.
The Queensland Court of Appeal in September 2007 dismissed an application to overturn the decision of the Supreme Court that refused to order a veterinary surgeon to provide a client with her case records for the client’s animals.
The Court of Appeal Judge said that there was no basis in law for making an order for the veterinary surgeon to hand over the records.
The Judge referred to a precedent case in the medical profession where the High Court found a client had no right to her medical records and that the doctor’s notes were his property, compiled for his own information in treating a patient.
The statutory requirement is that case records must be kept by a veterinary surgeon for a minimum of three years from the day the last information about the animal is recorded.
Radiographs are a diagnostic component of case records and as such the decision of the Queensland Court of Appeal outlined above would logically apply equally to diagnostic results.
That position is further strengthened by a documented body of opinion that a veterinarian takes an x-ray to make a diagnosis and the client is paying for that diagnosis, not the x-ray exposure itself. If a third party who is paid directly by the client takes the x-rays, they would in that case be the property of the client as is typically the case in general medical practice outside the public health system.
As x-rays are a part of the case record, the Veterinary Surgeons Regulation provides that the records be kept for three years.
The x-rays together with the balance of the case records can be released upon formal request to another veterinarian who has in turn gained the authorisation of the owner of the animal in question to transfer the x-rays and records and such x-rays and records should be returned to the originating veterinarian within a reasonable time.
Any x-rays together with the balance of the case records must be released upon formal request to another veterinarian who has in turn gained the authorisation of the owner of the animal in question to transfer the x-rays and records and such x-rays and records must be returned to the originating veterinarian within a reasonable time.
A veterinarian cannot defend himself/herself against any action if an independent assessment of a radiograph is that no diagnosis can be made from it.
Old and inadequate equipment should be replaced; developing solutions should be maintained at the required levels and replaced according to manufacturers instructions. The film should be identified at the time of exposure and include the name of the practitioner or practice, client and animal, the date, and should clearly indicate the left and right sides of the animal. Stick-on labels attached after developing are unacceptable.
All equipment must be registered with Radiation Health.
Information should be kept in a form that can be demonstrated as being made at the time the procedure was performed and can be authenticated e.g. a hard copy in a bound volume. A computer record does not meet this requirement.
The minimum requirement is a surgical log showing the name of the procedure, when done, how done and what was used.
Anaesthetic logs should detail pre-anaesthetic examination, types of drugs and amounts used (pre-med, induction and post), method of administration and duration.
Every practice should have a method to maintain a ‘register’ of anaesthetic procedures.
The general consensus is for practitioners to favour a handwritten register of anaesthetic procedures as they occur and to have this as a separate record to the patient’s general record. This could be a sheet that records details of anaesthetic procedures in a chronological order with single line entries for each anaesthetic, or the anaesthetic procedure could be described in more detail on an animal anaesthetic form which is kept in a anaesthetic register file.
All possible options should be taken to locate the owner of uncollected animals (telephone, visit to last known address, enquiries of neighbours, friends, relatives). If contacted, instructions should be gained, in writing if possible, for future of animal, e.g. collection by owner, adoption, transfer to local government refuge, euthanasia.
If the owner cannot be located and the veterinarian is confident the owner is not going to collect the animal, a certified letter should be forwarded to the last known address of the owner advising that if the animal is not collected by a specified date, the animal will be disposed of.
After the specified date, veterinarians should endeavour to have the animal adopted out either privately or through the local refuge but avoid having it euthanased unless it is in the animal’s best welfare due to suffering.
This type of situation could be avoided by the practice insisting that clients sign an appropriately worded ‘admission form’ prescribing the rights of the parties in the event of non-collection and entitling the practitioner to dispose of the animal in a certain time after non-collection.
The overriding principle is that a veterinarian should always act in a professional manner and should do what is thought is morally correct in all cases.
Where practices are boarding animals as distinct from hospitalising animals the Board’s policy is that there should be two separate and distinct accommodation areas. It must be perceived that the boarding area is an entirely different facility.
The Board acknowledges the stressful circumstances in which practitioners are placed when unexpected deaths occur in practice where it is difficult to tactfully and discretely recommend that a post-mortem examination be conducted.
The offer of a post-mortem should however always be given when there has been an unexplained death. In cases where the offer is initially refused and the veterinarian considers a dispute could arise, it is to the veterinarian’s benefit to press the point to the client that a post-mortem examination by an independent veterinarian employed at another practice or by a specialised pathology service should be undertaken to establish the cause of death.
In the interests of defusing any potential dispute arising from the death, an offer could be made to arrange an independent examination at either the owner’s expense or at the expense of the treating practice. At the least an in-house examination at no cost to the client should be offered.
A formal communication should be made by a referring veterinarian to a specialist providing information on the case. This is a critical component for the effectiveness of the veterinary referral process.
Specialists may not recognise cases as referrals without formal notification from the referring veterinarian.
The wishes of the referring veterinarian and the owner should be specified in the referral material.
The referring veterinarian should be provided with a detailed report on the outcome of the referral and if appropriate, the client should be advised to contact the referring veterinarian regarding continuing care of the patient.