Medical Records, Waste & Sharps

How long do I have to keep veterinary records?

See item no. 4 below. Per changes to the Veterinary Administrative Rules there is now a law that governs the data contained in and maintenance of records at a veterinary clinic: R338.4921 Medical records; requirements. Rule 21.

A veterinarian who practices veterinary medicine in Michigan shall maintain a medical record for each patient that accurately reflects the veterinarian’s evaluation and treatment of the patient. Entries in the patient record shall be made in a timely fashion. The patient record shall contain documentation of a valid veterinarian-patient-client relationship.

A record shall be maintained on either a herd or flock, or an individual patient. Records shall be legible and shall be retrievable. A record shall be maintained in either a written, electronic, audio, or photographic format.

A record for an individual patient, group, herd, or flock shall document all of the following:

1. Identification that may include, but not be limited to, a tattoo, tag number, lot number, pen number, age, name, markings, sex, and species of the patient, as available.
   
2. Date of the last veterinary service.
   
3. Name, address, and telephone number of the client.
   
4. Location of patients, if not at the location of the veterinary practice.
   
5. Reason for the contact including, but not limited to, the case history, problem and/or signs of a problem, and whether the contact was a routine health visit or an emergency call.
   
6. Vaccination history, when appropriate and if known.
   
7. Results of the physical examination and a list of abnormal findings.
   
8. Laboratory reports and other reports, when appropriate.
   
9. Diagnostic procedures utilized and the reports that pertain to these procedures.
   
10. Procedures performed including, but not limited to, surgery and rectal palpations.
    
11. Daily progress notes, if hospitalized.
    
12. Documentation of informed consent, if appropriate.
    
13. Documentation of diagnostic options and treatment plans.
    
14. Records of any client communication deemed relevant.
    
15. Documentation of prescribed medication.
    
16. Records shall be maintained for a minimum of 7 years from the date of the last veterinary service.
    

Based on the statute of limitations for bringing certain claims against veterinarians, other general record guidelines include professional malpractice (2 years), negligence (3 years), property damage (3 years) and breach of contract (6 years).

If a client asks for a copy of the animal’s record, what are my obligations?

There is no law regarding this subject in Michigan. While the records do belong to the veterinary practice, ethically the veterinarian should provide the client a copy or summary of the medical records when requested. The AVMA’s Principles of Veterinary Medical Ethics states as follows on the topic of medical records:

1. Veterinary medical records are an integral part of veterinary care.
   
2. Medical records are the property of the practice and the practice owner.
   
3. Ethically, the information within veterinary medical records is considered privileged and confidential. It must not be released except by court order or consent of the owner of the patient.
   
4. Veterinarians are obligated to provide copies or summaries of medical records when requested by the client.
   
5. Without the express permission of the practice owner, it is unethical for a veterinarian to remove, copy, or use the medical records or any part of any record.
   

Medical Waste and Sharps

Is there a list of State-approved medical waste removal services?

The Michigan Department of Environmental Quality has the best information.

What are sharps as defined by the state?

Sharps are part of the medical waste that is regulated by the State of Michigan. They include needles, scalpels, syringes and IV tubing with needles attached, and those parts of a syringe, with or without an attached needle, that are contaminated with an infectious agent.

How do I develop a plan for medical waste management at my practice?

The State of Michigan has provided several documents to help get you started:

• Michigan's Medical Waste Regulatory Program
  
• Sample Medical Waste Management Plan
  
• Medical Waste Regulatory Program Frequently Asked Questions
  
• Information on Sharps
  
• Sharps Collection Programs for Michigan Residents
  

Carcass Disposal

The Michigan Department of Agriculture & Rural Development's rules entitled "Bodies of Dead Animals" for on farm composting were approved with the Great Seal on September 26, 2007. The rules provide for composting of dead animals and animal tissue within a structure, in open piles, windrows, and contained vessels. These additional alternatives for disposal of dead animals will assist producers who have no rendering services, licensed landfills that accept dead animals, or soil types for proper burial. Learn More Here