Minimum Veterinary Practice Standards
Each veterinary medical facility shall comply with the following:
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:
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.
Name, address and telephone number of the owner and/or client;
Name, number or other identification of the animal and/or herd or flock;
Species, breed, age, sex, and color or distinctive markings, where applicable, each individual animal;
Vaccination history, if known, shall be part of the medical record;
Beginning and ending dates of custody of the animal;
Pertinent history and presenting complaint;
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.
For each physical exam the following conditions shall be evaluated and findings documented when applicable by species, even if such condition is normal:
Current weight or weight estimate for large animals;
Body condition or score;
Eyes, ears, nose and throat;
Cardiovascular and respiratory systems including heart rate and pulse, auscultation of the thorax, trachea, as species appropriate, and respiratory rate;
Evaluation of the abdomen by palpation and/or auscultation if applicable by species;
All data obtained by instrumentation;
If relevant, a prognosis of the animal’s condition;
Diagnosis or tentative diagnosis at the beginning of custody of animal;
Treatments and intended treatment plan, medications, immunizations administered, dosages, frequency and route of administration;
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’.
Surgical procedures shall be described including name of the surgeon, suture material used, and diagnostic findings;
Progress of the case while in the veterinary medical facility;
Exposed radiographs shall have permanent facility and animal identification;
If a client waives or declines any examinations, tests, or other recommended treatments, such waiver or denial shall be noted in the records.
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:
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;
The surgery room or area shall be clean, orderly, well-lighted and maintained in a sanitary condition;
All appropriate equipment shall be sterilized:
Chemical disinfection (“cold sterilization”) shall be used only for field conditions or antiseptic surgical procedures;
Provisions for sterilization shall include a steam pressure sterilizer (autoclave) or gas sterilizer (e.g., ethylene oxide) or equivalent.
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;
Minor surgical procedures shall be performed at least under antiseptic surgical techniques;
All animals shall be prepared for surgery as follows:
Clip and surgically prepare the surgical area for aseptic surgical procedures;
Loose hair must be removed from the surgical area;
Scrub the surgical area with appropriate surgical soap;
Disinfect the surgical area;
Drape the surgical area appropriately.
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:
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;
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;
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;
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.
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;
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;
Adequate means for resuscitation including intravenous catheter and fluids shall be available;
Emergency drugs shall be immediately available at all times;
While under sedation or general anesthesia, materials shall be provided to help prevent loss of body heat;
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;
Chemical restraint may be used in conjunction with, but not in lieu of, analgesic therapy;
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.
Library: A library of appropriate and current veterinary journals and textbooks or access to veterinary internet resources shall be available for ready reference.
Laboratory: Veterinarians shall have the capability for use of either in-house or outside laboratory service for appropriate diagnostic testing of animal samples.
Biologicals and drugs: The minimum standards for drug procedures shall be:
All biological substances shall be stored, maintained, administered, dispensed and prescribed in compliance with federal and state laws and manufacturers’ recommendations;
Controlled substances and legend drugs shall be dispensed, ordered or prescribed based on a VCPR and shall be labeled with the following:
Name of client and identification of animal(s);
Complete directions for use;
Name, strength, dosage and the amount of the drug dispensed;
Manufacturer’s expiration date;
Name of prescribing veterinarian and veterinary medical facility.
No biological or drug shall be administered or dispensed after the expiration date, for a fee.
If requested, a prescription shall be provided to a client for medications prescribed by the veterinarian under a valid VCPR.
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.
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;
The public shall be informed if an animal will be left unattended in the veterinary facility.
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.
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.