SECTION 775:25-1-2. Patient records

(a)   Each veterinarian shall maintain a legible patient record for three years, unless the records contain information with respect to the dispensation of veterinary prescription drugs, in which case the records shall be maintained for no less than five years. All patient records shall include the following necessary elements:

(1)   Patient identification shall include the patient's name, species, breed, age or date of birth, sex, color, and markings if applicable;

(2)   Client identification shall include the owner's name, home address and telephone number;

(3)   The vaccination record;

(4)   Physical examination findings to include diagnosis, treatment regimen, and medications dispensed, prescribed or administered; and

(5)   A record of every visit or stay on the veterinary premise.

(b)   Additionally, each veterinarian shall maintain records in a manner that will permit any authorized veterinarian to proceed with the care and treatment of the animal, if required, by reading the medical record of that particular patient. The record shall clearly explain the initial examination. (c) The veterinarian shall ensure that each dose of a medication administered is properly recorded on the patient's medical record, in addition to any medications dispensed or prescribed. All drugs administered, prescribed or dispensed shall only be done solely upon the order of a licensed veterinarian.

[Source: Added at 17 Ok Reg 1437, eff 5-11-00]