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Legal Issues of Documentation

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The intention of this section is to provide veterinary technicians with guidelines for writing the patient care plan portion of the veterinary medical record. As there is no standardized format for writing a veterinary care plan, the following principles are only one example of how a care plan may be formulated.

Because the veterinary medical record is a legal document, the following principles should be strictly adhered to when writing in the record:

  • The patient’s name and species and the owner’s name must be clearly written. Include this information on every page of the record.
  • Use black ink if the entries are handwritten.
  • Note the date and time at the beginning of each entry. The person making the entry should record his/her name and position at the end.
  • If an incorrect entry is made, draw a single line through the mistake. Write “error,” the name of the person making the change, the reason for correction, and the date next to the entry. Do not erase or obliterate any part of the record.
  • If a digital record-keeping system is used, the changes must be traceable and recorded in a manner similar to handwritten records.
  • Every aspect of a patient’s care must be documented. Legally, it is virtually impossible to prove a certain action was taken unless it was documented in the record.

Records are the legal property of the veterinary hospital and/or veterinarian(s) who own the practice. Information about a patient may only be released to the client at the discretion of the attending veterinarian. The client has a right to access all the information in the records.

*Some materials adapted from Rockett, J. et al. (2009). Patient Assessment, Intervention, and Documentation for the Veterinary Technician. Clifton Park, NY: Delmar.