Current through Register Vol. 63, No. 9, September 1, 2024
Each veterinary medical facility shall comply with the
following:
(1) Medical Records: A
legible individual record shall be maintained for each animal. However, the
medical record for a litter may be recorded either on the dam's record or on a
litter record until the individual animals are permanently placed or reach the
age of three months. Records for herd or flock animals may be maintained on a
group or client basis. All records shall be readily retrievable and must be
kept for a minimum of three (3) years following the last treatment or
examination. Records shall include, but are not limited to, the following
information:
(a) Name or initials of the
veterinarian responsible for entries; any written entry to a medical record
that is made subsequent to the date of treatment or service must include the
date that the entry was added.
(b)
Name, address and telephone number of the owner and/or client.
(c) Name, number or other identification of
the animal and/or herd or flock.
(d) Species, breed, age, sex, and color or
distinctive markings, where applicable, each individual animal.
(e) Vaccination history, if known, shall be
part of the medical record.
(f)
Beginning and ending dates of custody of the animal.
(g) Pertinent history and presenting
complaint.
(2) Required
examinations. Unless exempted under (1) of this section or the animal's
temperament precludes examination, a physical examination is required:
(a) To establish or maintain a
VCPR.
(b) Each time an animal is
presented with a new health problem.
(c) Within 24 hours of scheduled anesthesia.
And;
(d) If an animal is presented
for euthanasia. (May be limited to elements necessary for the humane
application of the procedure, such as a weight estimate and visual assessment
if necessary due to the patient's condition or temperament.)
(e) Examinations waived due to exemption or
temperament must be noted in the record. The veterinarian may waive
examinations not required by this section.
(f) For each physical exam the following
conditions shall be evaluated and findings documented when applicable by
species, even if such condition is normal.
(A) Temperature;
(B) Current weight or weight estimate for
large animals;
(C) Body condition
or score;
(D) Eyes, ears, nose and
throat;
(E) Oral cavity;
(F) Cardiovascular and respiratory systems
including heart rate and pulse, auscultation of the thorax, trachea, as species
appropriate, and respiratory rate;
(G) Evaluation of the abdomen by palpation
and/or auscultation if applicable by species;
(H) Lymph nodes;
(I) Musculoskeletal system;
(J) Neurological system;
(K) Genito/urinary system;
(L) Integumentary system
(M) All data obtained by
instrumentation;
(N) Diagnostic
assessment;
(O) If relevant, a
prognosis of the animal's condition;
(P) Diagnosis or tentative diagnosis at the
beginning of custody of animal;
(Q)
Treatments and intended treatment plan, medications, immunizations
administered, dosages, frequency and route of administration;
(R) All prescription or legend drugs
dispensed, ordered or prescribed shall be recorded including: dosage,
frequency, quantity and directions for use. Any changes made by
telecommunications shall be recorded. Legend drugs in original unopened
manufacturer's packaging dispensed or ordered for herd use are exempt from this
rule. Legend and prescription drugs are as defined by the U.S. Food and Drug
Administration in 'FDA and the Veterinarian'.
(S) Surgical procedures shall be described
including name of the surgeon, suture material used, and diagnostic
findings;
(T) Progress of the case
while in the veterinary medical facility;
(U) Exposed radiographs shall have permanent
facility and animal identification;
(V) If a client declines an examination, it
shall be noted in the medical records.
(W) If a client consents to or declines any
diagnostics, tests, or other recommended treatments, it shall be noted in the
medical records.
(3) Surgery: Surgery shall be performed in a
manner compatible with current veterinary practice with regard to anesthesia,
asepsis or antisepsis, life support and monitoring procedures, and recovery
care. The minimum standards for surgery shall be:
(a) Aseptic surgery shall be performed in a
room or area designated for that purpose and isolated from other activities
during the procedure. A separate, designated area is not necessarily required
for herd or flock animal surgery or antiseptic surgery;
(b) The surgery room or area shall be clean,
orderly, well-lighted and maintained in a sanitary condition:
(c) All appropriate equipment shall be
sterilized:
(A) Chemical disinfection ("cold
sterilization") shall be used only for field conditions or antiseptic surgical
procedures;
(B) Provisions for
sterilization shall include a steam pressure sterilizer (autoclave) or gas
sterilizer (e.g. ethylene oxide) or equivalent.
(d) For each aseptic surgical procedure, a
separate sterile surgical pack shall be used for each animal. Surgeons and
surgical assistants shall use aseptic technique throughout the entire surgical
procedure;
(e) Minor surgical
procedures shall be performed at least under antiseptic surgical
techniques;
(f) All animals shall
be prepared for surgery as follows:
(A) Clip
and surgically prepare the surgical area for aseptic surgical
procedures;
(B) Loose hair must be
removed from the surgical area;
(C)
Scrub the surgical area with appropriate surgical soap;
(D) Disinfect the surgical area;
(E) Drape the surgical area
appropriately.
(4) A veterinarian shall use appropriate and
humane methods of anesthesia, analgesia and sedation to minimize pain and
distress during any procedures or conditions and shall comply with the
following standards:
(a) Animals shall have a
documented physical exam conducted within 24 hours prior to the administration
of a sedative or anesthetic, which is necessary for veterinary procedures,
unless the temperament of the patient precludes an exam prior to the use of
chemical restraint;
(b) An animal
under general anesthesia for a medical or surgical procedure shall be under
direct observation throughout the anesthetic period and during recovery from
anesthesia until the patient is awake and in sternal recumbency;
(c) A method of cardiac monitoring shall be
employed to assess heart rate and rhythm repeatedly during anesthesia and may
include a stethoscope or electronic monitor;
(d) A method of monitoring the respiratory
system shall be employed to assess respiratory rate and pattern repeatedly
during anesthesia and may include a stethoscope or electronic
monitor.
(e) Where general
anesthesia is performed in a hospital or clinic for companion animal species
(excluding farm animals), anesthetic equipment available shall include an
oxygen source, equipment to maintain an open airway and a
stethoscope;
(f) Anesthetic and
sedation procedures and anesthetic and sedative medications used shall be
documented, including agent used, dosage, route of administration, and
strength, if available in more than one strength;
(g) Adequate means for resuscitation
including intravenous catheter and fluids shall be available;
(h) Emergency drugs shall be immediately
available at all times;
(i) While
under sedation or general anesthesia, materials shall be provided to help
prevent loss of body heat;
(j)
Analgesic medications, techniques and/or husbandry methods shall be used to
prevent and minimize pain in animals experiencing or expected to experience
pain, including but not limited to all surgical procedures;
(k) Chemical restraint may be used in
conjunction with, but not in lieu of, analgesic therapy;
(l) Appropriate analgesic therapy shall be
guided by information specific to each case, including but not limited to
species, breed, patient health and behavioral characteristics, the procedure
performed, and the expected degree and duration of pain.
(5) Library: A library of appropriate and
current veterinary journals and textbooks or access to veterinary internet
resources shall be available for ready reference.
(6) Laboratory: Veterinarians shall have the
capability for use of either in-house or outside laboratory service for
appropriate diagnostic testing of animal samples.
(7) Biologicals and drugs: The minimum
standards for drug procedures shall be:
(a)
All biological substances shall be stored, maintained, administered, dispensed
and prescribed in compliance with federal and state laws and manufacturers'
recommendations;
(b) Controlled
substances and legend drugs shall be dispensed, ordered or prescribed based on
a VCPR and shall be labeled with the following:
(A) Name of client and identification of
animal(s);
(B) Date
dispensed;
(C) Complete directions
for use;
(D) Name, strength, dosage
and the amount of the drug dispensed;
(E) Manufacturer's expiration date;
(F) Name of prescribing veterinarian and
veterinary medical facility.
(c) No biological or drug shall be
administered or dispensed after the expiration date, for a fee.
(d) Rabies vaccine shall be administered only
by an Oregon-licensed veterinarian, a Certified Veterinary Technician under
direct supervision of an Oregon-licensed veterinarian, or a person authorized
by the Oregon Public Health Veterinarian pursuant to OAR
333-019-0017.
(e) If requested, a
prescription shall be provided to a client for medications prescribed by the
veterinarian under a valid VCPR.
(8) A veterinarian shall not use, or
participate in the use of, any form of advertising or solicitation which
contains a false, deceptive or misleading statement or claim.
(a) Specialty Services: Veterinarians shall
not make a statement or claim as a specialist or specialty practice unless the
veterinarian is a diplomate of a recognized specialty organization of the
American Veterinary Medical Association;
(b) The public shall be informed if an animal
will be left unattended in the veterinary facility.
(9) The veterinarian shall be readily
available or has arranged for emergency coverage or follow-up evaluation in the
event of adverse reaction or the failure of the treatment regimen.
(10) Euthanasia: Documented consent shall be
obtained and a physical exam conducted prior to performing euthanasia. The exam
may be limited to the elements necessary for the humane application of the
procedure, such as a weight estimate and visual assessment if necessary due to
the patient's condition or temperament. When ownership and identification of an
animal cannot be reasonably established, the medical record for euthanasia
shall contain a physical description of the animal.
Statutory/Other Authority: ORS
686.210
Statutes/Other Implemented: ORS
686.040 & ORS
686.370
