NAC638.0475. Maintenance and availability of records; required contents of records; cessation of practice without providing for continuation of treatment.

     1. Each licensed veterinarian shall maintain in this State for at least 4 years a separate medical record of each animal receiving veterinary services, including, without limitation, an examination conducted pursuant to NAC 638.610, from the licensed veterinarian or under his or her supervision. The records must be available for inspection by the owner of the animal during normal business hours at least 5 days each week. Except as otherwise provided in this subsection, the licensed veterinarian shall provide a copy of that record to the owner of the animal receiving veterinary services not later than 48 hours after receiving a request from the owner of the animal. The licensed veterinarian is not required to provide a copy of any radiographs or other diagnostic images in the medical record to the owner of the animal receiving veterinary services.

     2. The medical record must contain the following information, in legible form:

     (a) The name, address and telephone number of the animal’s owner;

     (b) The name or identifying number, or both, of the animal;

     (c) The age, sex, weight and breed of the animal;

     (d) The dates of care, custody or treatment of the animal;

     (e) A short history of the animal’s condition as it pertains to the animal’s medical status;

     (f) The results of and notations from an examination of the animal, including, without limitation, the temperature, pulse and respiration rate of the animal and laboratory data pertaining to the animal;

     (g) The diagnosis or condition at the beginning of custody of the animal, including, without limitation, results of tests;

     (h) The immunization record of the animal;

     (i) All clinical information pertaining to the animal, including, without limitation, sufficient information to justify the diagnosis or determination of the medical status of the animal and to warrant any treatment recommended for or administered to the animal;

     (j) The notes taken during surgery, including, without limitation:

          (1) The name and quantity of any drug administered for anesthesia and preanesthesia;

          (2) The procedure performed;

          (3) The times at which the surgery begins and ends;

          (4) If the surgery is performed in a veterinary facility using general anesthesia:

               (I) The vital signs of the animal at the beginning and end of the surgery that are appropriate to the species and condition of the animal at the time of surgery, which may include, without limitation, the temperature, pulse, heart rate, respiration, blood pressure, capillary refill time and oxygen levels of the animal; and

               (II) The vital signs of the animal recorded at least every 5 minutes during the surgery, including, without limitation, the pulse, heart rate and respiration of the animal;

     (k) Any medication and treatment administered, including, without limitation, the amount and frequency;

     (l) The progress and disposition of the case;

     (m) The name of each person who is not an employee of the veterinarian who provided professional advice or performed treatments, examinations or other services pertaining to the animal;

     (n) Any radiographs other than inter-oral dental radiographs. Each radiograph other than an inter-oral dental radiograph must be labeled in the emulsion film as follows:

          (1) The name of the veterinarian or facility that took the radiograph;

          (2) The name or identifying number, or both, of the animal;

          (3) The name of the animal’s owner;

          (4) The date on which the radiograph was taken; and

          (5) The anatomical orientation depicted by the radiograph; and

     (o) Any inter-oral dental radiographs or other diagnostic images. For each inter-oral dental radiograph or other diagnostic image, the medical record must include the information set forth in subparagraphs (1) to (5), inclusive, of paragraph (n) with regard to the inter-oral dental radiograph or other diagnostic image. That information may be included:

          (1) In a hard copy of the medical record if the medical record is maintained as a written record; or

          (2) In the computer file which contains the inter-oral dental radiograph or other diagnostic image if the medical record is maintained as a computer record.

     3. Each radiograph or other diagnostic image is the property of the veterinarian who caused it to be prepared. A radiograph or other diagnostic image may be released to the owner of the animal. A radiograph or other diagnostic image must be released within 48 hours after the request is made to another veterinarian who has the authorization of the owner of the animal to which it pertains. The radiograph or other diagnostic image must be returned within a reasonable time to the veterinarian to whom it belongs.

     4. The medical records required by this section must be written records or computer records. If the medical records are computer records:

     (a) The security of the computer must be maintained.

     (b) The computer records must be backed-up daily and cumulatively backed-up monthly using technology designed to store data permanently.

     (c) The computer records must be inalterable or clearly indicate when they have been altered and the manner in which they have been altered.

     (d) The computer records must not contain information relating to a physical examination that is automatically generated by the computer.

     (e) Any such computer records relating to the administration, prescribing or dispensing of a prescription drug must contain the initials of the person who administered, prescribed or dispensed the prescription drug. The initials of the person who administered, prescribed or dispensed the prescription drug may be manually entered into the computer record or automatically generated by the computer.

     5. In a practice concerned with herds of animals, records must be kept on each herd and may be kept on individual animals.

     6. If a veterinarian ceases his or her practice without providing for the continuation of treatment of the animals under the veterinarian’s care, the President of the Board may appoint a master to supervise his or her records, the treatment of those animals and the mailing of notices to the owners of the animals which had been under his or her care.

     7. The medical record of an animal is confidential and may not be released except:

     (a) As otherwise provided in subsection 1;

     (b) In response to a court order; or

     (c) As required to ensure compliance with any federal, state and local statutes, regulations or ordinances.

     8. Nothing in this section is intended to prevent the sharing of veterinary medical information among veterinarians, law enforcement officials, and members, agents or officers of a society for the prevention of cruelty to animals who are acting to protect the welfare of an animal.

     9. As used in this section, “other diagnostic image”:

     (a) Includes, without limitation, an ultrasound, magnetic resonance imaging and computerized axial tomography scan; and

     (b) Does not include a radiograph.

     (Added to NAC by Bd. of Veterinary Med. Exam’rs, eff. 3-19-86; A 7-7-94; R049-98, 8-5-98; R115-99, 12-7-99; R130-04, 1-26-2005; R074-06, 6-28-2006; R116-10, 12-30-2011, eff. 1-1-2012)