Section 5.01 - Medical Records(1) A licensee shall maintain a legible record for each patient. The identity of the author of all medical records shall be clearly noted on all records by either signature or initials. The original medical records and images shall be maintained and readily available for four years after the last contact with the animal. Upon the request of the owner, copies of the medical record and images shall be provided to the owner or another veterinarian. A reasonable fee may be charged for the cost of such copies, but the records may not be withheld because of an outstanding balance due to the licensee. (2) A licensee shall accurately record the following information on each animal's medical record: (a) the owner's name, address, telephone number(s), or contact information; (b) the animal's name, any applicable identification number(s), species, breed, date of birth, sex, color, markings and current weight; (c) the date, presenting complaint, pertinent history, examination findings, and a plan for diagnostics, treatment and care; (d) appropriate information to justify any tentative diagnosis and to warrant any treatment at the time of data entry on the record; (e) all vaccines administered; (f) all laboratory tests; (g) all imaging evaluations; (h) all professional consultation reports; (i) all consent forms, such as anesthesia, surgery, euthanasia and necropsy consent forms, or child-resistant container waivers; (j) all treatments provided, both medical and surgical; (k) all dental procedures; (l) all medication given, including the date, dosage, route of administration, frequency, duration of treatment and refills; (m) all medication dispensed or prescribed, including directions for use and quantity; (n) all changes in medication or doses, including changes made by telephone; (o) all client communications; (p) all client waivers or deferrals of recommended care; (q) all discharge instructions; and (r) all necropsy findings. (3) Medical records for groups of animals such as sheep and fish may be maintained on a per client basis when treated as a group.Amended by Mass Register Issue 1339, eff. 5/19/2017.