PROPOSED RULEMAKING
STATE BOARD OF VETERINARY MEDICINE
[49 PA. CODE CH. 31]
Recordkeeping
[36 Pa.B. 5984]
[Saturday, September 30, 2006]The State Board of Veterinary Medicine (Board) proposes to amend § 31.22 (relating to recordkeeping rationale) to read as set forth in Annex A. The proposed rulemaking provides greater specificity to the Board's existing recordkeeping regulation. In addition, the proposed rulemaking sets forth the proper procedures for a veterinarian who is retiring or closing an office. Finally, the proposed rulemaking provides mandates for veterinary medical records from vaccine clinics.
Effective Date
The proposed rulemaking will be effective upon final-form publication in the Pennsylvania Bulletin.
Statutory Authority
Section 27.1 of the Veterinary Medicine Practice Act (act) (63 P. S. § 485.27a) requires the Board to promulgate regulations setting forth recordkeeping standards.
Background and Need for Amendment
Through the adjudication of numerous disciplinary cases over the past several years, the Board has determined the need to set additional requirements in its regulation of veterinary medical recordkeeping.
The reasons for this proposed rulemaking are threefold. First, the proposed rulemaking mandates contents of medical records and further defines acceptable standards of veterinary medical recordkeeping practice in this Commonwealth. Second, the Board proposes minimum standards of records when veterinarians provide service in vaccination clinics. Finally, the Board proposes to add paragraph (10) to provide mandates for veterinarians who are retiring or closing their veterinary practices.
The Board is aware of the public health benefits of vaccination clinics. Public health vaccination clinics inoculate animals against diseases, such as rabies, that pose a threat to human health. Public health clinics are relatively common in this Commonwealth and serve to promote public health and safety. Animal health vaccination clinics inoculate animals against diseases, such as distemper, that pose a threat to animal health. Some animal owners do not obtain routine animal health vaccinations at a veterinary office. Thus, animal health vaccination clinics, while not ideal, serve to promote animal health and welfare.
Veterinarians have expressed confusion over the minimum recordkeeping requirements for these clinics. The proposed rulemaking recognizes that the acceptable and prevailing standards of practice for recordkeeping for public health and animal health vaccination clinics require only a minimum of information as compared to the entire veterinary medical record, of which vaccine history is but one part. The proposed rulemaking protects the public by mandating that a veterinarian who participates in a vaccination clinic provide a means for clients to obtain information should an adverse reaction occur.
Finally, the Board has received numerous inquiries regarding a veterinarian's recordkeeping responsibilities when closing a veterinary practice, which the Board also addresses in this proposed rulemaking.
Description of Proposed Amendments
The general requirement that records be kept so that a veterinarian may, by reading the record, proceed with the proper care and treatment of an animal has been moved from current § 31.22(1). The proposed rulemaking would adopt the problem oriented medical record (POMR) or similar recordkeeping system. POMR is a recognized standard form of all medical recordkeeping. It involves creation of a record listing subjective and objective data, assessment and evaluation and a treatment plan. POMR recordkeeping is taught in all schools of veterinary medicine as the standard for veterinary practice. The Board also proposes language to note that the Board reviews veterinary medical records to determine the advice given and treatment recommended and performed by a veterinarian. Current paragraph (1) is deleted.
Proposed paragraph (1) is a general provision that requires a separate veterinary medical record for each patient, herd or group, as appropriate. This requirement accounts for differences in practice between veterinarians whose patients are companion animals and veterinarians whose patients are production animals. Proposed paragraph (1) also requires that veterinary medical records be accurate, legible and complete, as more fully set forth in proposed paragraph (3). Finally, proposed paragraph (1) requires that the veterinary medical record identify the treating individual after each entry. This requirement assists in communication among members of a practice or a subsequent treating veterinarian and allows for accurate review of the treatment provided to an animal.
Proposed paragraph (2) sets forth specific requirements for identifying the patient, herd or group. This paragraph is drafted to apply to both companion and production animals.
Proposed paragraph (3) sets forth the specific requirements for documenting the animal's medical history, tests, diagnoses and treatment provided.
Proposed paragraph (4) sets forth requirements for documentation of client communication. This documentation is not mandated for production animal records. Production animal owners or herdsmen are generally knowledgeable and veterinarians for production animals often communicate telephonically with clients when veterinarians are not in offices where they could easily place notes in the clients' records. In these cases, the customary and acceptable practice is for veterinarians to record only that information that is medically significant. In addition, Federal law and regulation stringently regulate the recordkeeping requirements for these veterinarians. The Board concluded that it was not necessary to mandate that client communication be documented in production animal medical records.
The Board proposes to move the current mandate that veterinarians retain records for 3 years from current paragraph (1) to proposed paragraph (5).
The Board proposes to renumber paragraphs (2)--(4) as paragraphs (6)--(8). In proposed paragraph (8), the Board provides a time frame for the provision of veterinary medical records. The Board determined that a period of 3 business days from receipt of the client's written request for records was reasonable and would be workable even if the veterinarian were out of the office when the request was sent.
The Board proposes to add paragraph (9) regarding veterinary medical records for vaccination clinics. The proposed rulemaking balances the need for pertinent information with the need for brevity in the vaccination clinic setting by requiring only the most important information be recorded in that setting.
The Board proposes to add paragraph (10) to provide mandates for veterinarians who are retiring or closing their veterinary practices.
Regulated Communities
In drafting this proposed rulemaking, the Board solicited input from the State and regional veterinary medical associations. In addition, the Board specifically solicited input from production animal veterinarians.
Fiscal Impact
The proposed rulemaking should not have any fiscal impact on the Board's licensees or any other public or private group or sector.
Paperwork Requirements
The proposed rulemaking sets forth the existing acceptable standards of practice for recordkeeping. The proposed rulemaking does not enlarge the time that veterinarians must maintain veterinary medical records. There are not additional paperwork requirements created by the proposed rulemaking.
Sunset Date
The Board continuously monitors its regulations. Therefore, no sunset date has been assigned.
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on September 20, 2006, the Board submitted a copy of this proposed rulemaking and a copy of a Regulatory Analysis Form to the Independent Regulatory Review Commission (IRRC) and to the Chairpersons of the Senate Consumer Protection and Professional Licensure Committee and the House Professional Licensure Committee. A copy of this material is available to the public upon request.
Under section 5(g) of the Regulatory Review Act, IRRC may convey any comments, recommendations or objections to the proposed rulemaking within 30 days of the close of the public comment period. The comments, recommendations or objections must specify the regulatory review criteria which have not been met. The Regulatory Review Act specifies detailed procedures for review, prior to final publication of the rulemaking, by the Board, the General Assembly and the Governor of comments, recommendations or objections raised.
Public Comment
Interested persons are invited to submit written comments, suggestions or objections regarding this proposed rulemaking to Robert Kline, Administrator, State Board of Veterinary Medicine, P. O. Box 2649, Harrisburg, PA 17105-2649 within 30 days following publication of this proposed rulemaking in the Pennsylvania Bulletin.
THOMAS J. MCGRATH, D.V.M.,
ChairpersonFiscal Note: 16A-5719. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 49. PROFESSIONAL AND VOCATIONAL STANDARDS
PART I. DEPARTMENT OF STATE
Subpart A. PROFESSIONAL AND OCCUPATIONAL AFFAIRS
CHAPTER 31. STATE BOARD OF VETERINARY MEDICINE
PROFESSIONAL CONDUCT § 31.22. Recordkeeping [rationale].
Veterinary medical records serve as a basis for planning animal care and as a means of communicating among members of the veterinary practice. The records furnish documentary evidence of the animal's illness, hospital care and treatment and serve as a basis for review, study and evaluation of the care and treatment rendered by the veterinarian. A veterinary medical record shall be kept in a problem-oriented or similar format that allows any veterinarian, by reading the record, to proceed with the care and treatment of the animal and allow the Board or other agency to determine the advice and treatment recommended and performed. This section does not apply to laboratory animal practice.
(1) [Record retention. A veterinarian shall maintain veterinary medical records of an animal so that any veterinarian coming into a veterinary practice may, by reading the veterinary medical record of a particular animal, be able to proceed with the proper care and treatment of the animal. Records shall be maintained for a minimum of 3 years from the date that the animal was last treated by the veterinarian.]
Record required. A veterinarian shall maintain a separate veterinary medical record for each patient, herd or group, as appropriate, which accurately, legibly and completely reflects the evaluation and treatment of the patient or patients. The veterinary medical record must identify the treating individual after each chart entry.
(2) Identity of patient. The veterinary medical record must include, at a minimum, the following information to identify the patient, herd or group:
(i) Client identification.
(ii) Appropriate patient identification, which may include species, breed, age, sex, weight, name or identity number or numbers, color and identifying markings, and whether neutered, spayed or intact.
(3) Minimum content of record. The veterinary medical record must include:
(i) Vaccination history.
(ii) Previous medical history, presenting symptoms and complaint.
(iii) Date of each examination.
(iv) Diagnosis.
(v) Results and findings of pathological or clinical laboratory examination.
(vi) Findings of radiological examination.
(vii) Medical or surgical treatment.
(viii) Other diagnostic, corrective or therapeutic procedures.
(ix) Documentation of drugs administered, prescribed or dispensed, including dosage.
(x) Documentation of surgical and dental procedures, including type and dosage of anesthesia, and dental charting.
(4) Communication with client. The veterinary medical record of any animal, except a production animal, shall document communication with the client, including the client's consent to or rejection of recommended diagnostic tests, treatments and drugs.
(5) Retention of records. Records shall be maintained for a minimum of 3 years from the date that the animal was last treated by the veterinarian.
[(2)] (6) * * *
[(3)] (7) * * *
[(4)] (8) Release of information to clients. A veterinarian shall release a summary or a copy of the veterinary medical records of an animal to the client [upon] within 3 business days of receipt of the client's written request. A veterinarian may charge a reasonable fee for duplicating veterinary medical records and for preparation of veterinary medical record file summaries for release to clients. A veterinarian may not withhold the release of veterinary medical records or summaries to clients for nonpayment of a professional fee. The release of veterinary medical records or summaries to clients under these circumstances does not constitute a waiver by the veterinarian of the fee claimed.
(9) Veterinary medical records for vaccination clinics. A veterinarian providing veterinary medical services to the public for a public health vaccination clinic or an animal health vaccination clinic shall prepare a veterinary medical record that includes, at a minimum, an identification of the client and patient, the vaccine lot number, and the date and dosage administered. A veterinarian who provides veterinary medical services to a vaccination clinic shall provide a means for clients to obtain advice pertaining to postvaccine reactions for the 24-hour period immediately following the time of vaccination.
(10) Veterinary records of retiring veterinarian or a veterinary practice that is closing. A veterinarian shall notify clients, in writing, at least 30 days prior to the date of a planned retirement or closing of a veterinary practice. The written notice must include instructions on how to obtain copies of veterinary medical records from the veterinarian or other custodian of the records and the name, address and telephone number of the person purchasing the practice, if applicable. Veterinary medical records must remain available to clients for 3 years after the date the veterinarian retires or the practice is closed. If prior notice could not be provided, a successor veterinarian shall notify clients within 60 days of the date the successor takes over the practice.
[Pa.B. Doc. No. 06-1907. Filed for public inspection September 29, 2006, 9:00 a.m.]
No part of the information on this site may be reproduced for profit or sold for profit.This material has been drawn directly from the official Pennsylvania Bulletin full text database. Due to the limitations of HTML or differences in display capabilities of different browsers, this version may differ slightly from the official printed version.
