201 Ky. Admin. Regs. 16:701
Current through Register Vol. 51, No. 6, December 1, 2024
Section 201 KAR 16:701 - Standards for medical recordsRELATES TO: KRS 257.080, 258.043, 258.065, 321.175, 321.181, 321.185, 321.187, 321.188, 321.200
NECESSITY, FUNCTION, AND CONFORMITY: KRS 321.175 establishes that the purpose of the Kentucky Veterinary Medicine Practice Act is to promote, preserve, and protect public health, safety, and welfare. KRS 321.235(2)(b) 3.c. authorizes the Kentucky Board of Veterinary Examiners to promulgate administrative regulations to establish standards in medical records. This administrative regulation establishes standards for medical records created for animal patients by board credential holders.
Section 1. Definitions. (1) "Clinical encounter" means an interaction between a patient, client, and a healthcare provider for the purpose of providing healthcare services or assessing the health status of a patient and is the point at which decisions about diagnosis and treatment are made and during which care takes place.(2) "Complete medical record" means the record contains sufficient information to: (a) Identify the patient and the client;(b) Support the diagnosis or condition;(c) Justify the care, treatment, and services;(d) Provide options for spectrum of care, where appropriate;(e) Document the course and results of care, treatment, and services; and(f) Promote continuity of care among providers.Section 2. Veterinary medical records shall be:(1) Safeguarded against loss, tampering, or use by unauthorized persons;(2) Be readily available to the veterinarian, other veterinarians at the same practice, employees of the veterinarian, and other authorized persons;(3) Contain sufficient information to permit any veterinarian to proceed with the care and treatment of the patient by reading the medical record; and(4) Be completed no more than forty-eight (48) hours following the clinical encounter.Section 3. Maintenance of Records. (1) Medical records shall be maintained in accordance with KRS 321.187.(2) Cessation from practice, either temporarily or permanently, shall not relieve the practitioner from compliance with this section.(3) Records stored by a third party shall not relieve the veterinarian or AAHP from the responsibility of supplying records to the client upon request.(4) There shall not be a charge for a board investigation.Section 4. Veterinary medical records shall, at a minimum, include: (1) Patient or herd identification;(2) Client identification;(3) A record of every clinical encounter and consultation regarding the patient;(4) Written or digital records and notes of each clinical encounter, including:(a) Diagnosis or differential diagnosis;(b) Treatments recommended, including spectrum of care options;(c) Treatment plan agreed upon with client;(d) If a prescription is issued, prescription details consistent with the requirements of 201 KAR 16:600;(f) If a medical determination is made via telemedicine, a written statement about the digital information used to make the decision;(g) If surgery is performed, details of surgery, including:1. Amounts and duration of any drugs, sedatives, or other substances administered;2. Documentation of appropriate, species-specific anesthetic monitoring, which may include temperature, pulse, and respiration;3. Documentation of recovery; and4. Materials used, including at a minimum: c. Other materials used; and(h) Any other pertinent details;(6) Any information received as the result of a consultation, including the date, name, and contact information of the consultant;(7) A reference notation of the existence of radiographs, sonographic images, video recordings, photographs, or other diagnostic imaging, with ready access to or copies of those images available;(8) Any authorizations, details of conversations, releases, waivers, patient discharge instructions, records of informed consent, or other related documents;(9) The first and last name of the veterinarian, licensed veterinary technician, or veterinary assistant, or AAHP permit holder practicing on the patient during the visit, whether in-person or via telehealth, or an identifying code that corresponds to the first and last name of the practitioner or person making the entry pursuant to subsection (12) of this section;(10) The first and last name of the person making each entry in the medical record, or an identifying code for each person pursuant to subsection (12) of this section;(11) The name of the veterinary facility or premises where the clinical encounter took place; and(12) If an identifying code is used to denote the first and last name of the person making an entry into the medical record, a list of identifying codes and corresponding first and last names shall be made readily available with the medical records to the client or the board upon request.Section 5.(1) A person shall not: (a) Intentionally create a false record;(b) Make a false statement; or(c) Alter or modify any medical record, document, or report concerning treatment of a patient.(2) When correcting a completed medical record for a clinical encounter, the original content shall be readable, and the alteration shall be clearly identified with the: (b) Reason for the correction;(c) Date of correction; and(d) First and last name of the person making the correction, or an identifying code pursuant to Section 4(12) of this administrative regulation.Section 6. Rabies Clinics. (1) During each rabies clinic held pursuant to KRS 258.043, copies of medical records shall be retained for each patient clinical encounter beyond the rabies vaccination.(2) For rabies vaccinations only, a copy of the rabies certificate satisfies the requirement of this section.Section 7. Confidentiality of Records. Medical records shall be kept confidential in accordance with KRS 321.187(6).50 Ky.R. 518, 1309, 1482; eff. 4/2/2024.STATUTORY AUTHORITY: KRS 321.175, 321.187, 321.235(2)(b) 3.c.