Ohio Administrative Code
Title 4741 - State Veterinary Medical Licensing Board
Chapter 4741-1 - General Provisions
Section 4741-1-21 - Recordkeeping

Universal Citation: OH Admin Code 4741-1-21

Current through all regulations passed and filed through September 16, 2024

(A) A veterinarian performing a physical examination, diagnosis, treatment or surgery on an animal or group of animals shall prepare a written record or computer record concerning the animals containing, at a minimum, the following information:

(1) Name, address, and telephone number of owner;

(2) Identity of the animal, herd, or flock;

(3) Except for herds or flocks, the age, sex, color, and breed;

(4) Dates of examination, treatment and surgery;

(5) Brief history of the condition of each animal, litter, herd, or flock;

(6) Examination findings;

(7) Laboratory and radiographic tests performed and reports;

(8) Differential diagnosis;

(9) Procedures performed/treatment given and results;

(10) Drugs (and their dosages and routes of administration) administered, dispensed, or prescribed;

(11) Surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agent used, the route of administration and the dosage; and

(12) Anesthesia monitoring performed during surgical procedures.

(B) Individual records must be maintained on each patient, except that records on livestock or litters of animals may be maintained on a per-client basis.

(C) Medical records and radiographs are the physical property of the hospital or the proprietor of the practice that prepared them. Records, including radiographs, must be mintained for a minimum of three years after the last visit.

(D) Medical records shall be released upon request from a treating veterinarian with a legitimate interest, and shall be returned to the originating practice within a reasonable time if requested. Copies of records must be made available upon request from the owner of an animal at a reasonable cost to the owner and within a reasonable time. A veterinarian may not withhold the release of veterinary medical records for nonpayment of a professional fee.

(E) All regulated substances shall be recorded as required by federal and/or state regulations

Disclaimer: These regulations may not be the most recent version. Ohio may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.