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(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 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, discharged;

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

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

(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 he/she has performed, or which he/she has directed support personnel to perform.

(e) All radiographs shall be permanently labeled to identify the veterinarian or premise, 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.

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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