VN 13. Clinical and client records

Clinical and client records

13.1  Clinical and client records should include details of examination, treatment administered, procedures undertaken, medication prescribed and/or supplied (and if supplied against a verbal prescription, the reason for prescribing it), the results of any diagnostic or laboratory tests (including, for example, radiograph, ultrasound or electrocardiogram images or scans), provisional or confirmed diagnoses, and advice given to the client (whether over the telephone or in person). They should also include outline plans for future treatment or investigations, details of proposed follow-up care or advice, notes of telephone conversations, fee estimates or quotations, consents given or withheld, contact details and any recommendations or discussion about referral or re-direction.

13.2  The utmost care is essential in writing records or recording a client's personal details to ensure that they are clear, legible, accurate and appropriately detailed. Clinical and client records should be objective and factual, and veterinary surgeons and veterinary nurses should avoid making personal observations or assumptions about a client’s motivation, financial circumstances or other matters.

13.3  Ideally, client financial information and any other personal or sensitive information should be recorded separately from clinical records. This is because only relevant clinical information / information in the interests of the treatment of the animal should be provided to colleagues taking over responsibility for a case. It is however acceptable to include a statement in the clinical records that treatment has been limited or declined by the client for financial or other reasons.

13.4  Explicit consent may be required in order to record and use certain personal or special category data (previously known as sensitive personal data) about a client, such as any access needs of the client or other health information.

13.5  It may be permissible to mark the client record to indicate that the client is aggressive, violent etc, without client consent, on the basis that an employer has a legitimate interest to record such information so as to afford protection to their employees. If practicable, veterinary surgeons and veterinary nurses should inform the client that the flag has been put on their record and why, and the flag should be reviewed periodically. Likewise, it may be permissible to mark the client record to indicate that a client is a bad debtor without client consent, on the basis that there is a legitimate interest for the business to get paid for the services it provides. Ideally, the practice’s privacy policy would state that the practice may flag client records for these reasons, in which case it would not be necessary to notify individual clients if and when it occurs.

Amendments and additions

13.6  Clinical and client records should be made at the time of the events being recorded or as soon as possible afterwards. There may however be justifiable reasons to retrospectively amend clinical records, for example, in order to correct an inaccurate entry or to include additional information. In such cases, the amendment, the details of the person making the amendment and the date on which it is made should be clearly marked. Any correction should, where possible, be noted alongside the relevant entry. Care should be taken not to obliterate the original entry. This is to avoid giving rise to allegations that the amendments have been made unprofessionally or dishonestly. 

13.7  Veterinary surgeons and veterinary nurses should take extra care when using older electronic records systems, which allow for the deletion or over-writing of the previous records. This is to ensure that mistakes and inadvertent amendments are not made.

13.8  If multiple team members are involved in updating the same clinical record, it is important to make sure that the identity of the person making the entry is clear.

Dealing with factual inaccuracies 

13.9  Clients have the right under the GDPR to request the rectification of personal data if it is inaccurate or incomplete.

13.10  In some cases, clients may consider that information contained within the records, that is not their personal data, is inaccurate or incorrect and may request that the information be corrected. If a client objects to or complains about an entry in their records, veterinary surgeons and veterinary nurses should discuss the client’s concerns with them and make a record of the discussion. It should be noted, however, that diagnosis and clinical opinion is a matter of clinical judgement and should not be changed solely at the client’s request. There is no obligation to amend professional opinion. If, however, the veterinary surgeon or veterinary nurse agrees that the records should be amended due to errors or factual inaccuracies, the advice above should be followed. 

13.11  If, after discussion and following the steps above, the client remains dissatisfied, the most appropriate course of action may be to insert the client’s opinion alongside that of the veterinary professional, making it clear that the additions were inserted at the client’s request. It is helpful to remind the client that an alteration to an electronic record is always preserved (together with the original entry) as part of the audit trail.

Access to clinical and client records

13.12  Clinical and client records including diagnostic images and similar records, are the property of, and should be retained by, veterinary surgeons in the interests of animal welfare and for their own protection.  Although clients do not own their clinical records, they have the right to access information about themselves under data protection legislation as well as under professional guidelines set by the RCVS.

13.13  The GDPR gives individuals the right to access their personal data. To clarify, the GDPR relates to personal data – data about an individual person. Information about an animal is not personal data and is outside the scope of the GDPR. Unless the subject access request is excessive or repetitive, a copy of the information must be provided free of charge, and the information should generally be provided without delay and no later than one month after receipt of the request. This is subject to certain exceptions. Care must be taken where the disclosure would involve disclosing another individual’s personal data or confidential information. In such cases, consider seeking legal advice or read the Information Commissioner’s Office’s (ICO’s) guidance on subject access requests. Veterinary surgeons and veterinary nurses may need to seek the consent of other people to the disclosure of their personal data, or consider redacting it where appropriate. 

13.14  Under RCVS guidelines, at the request of a client, veterinary surgeons and veterinary nurses must provide copies of any relevant clinical and client records. This includes relevant records which have come from other practices, if they relate to the same animal and the same client, but does not include records which relate to the same animal but a different client.

13.15  In many cases it will be made clear to clients that they are not being charged for radiographs or laboratory reports, but for diagnosis or advice only. In situations where images are held on film, the film remains the property of the practice, with the client being charged for diagnosis or advice. In this situation, copies should still be provided in response to a request, wherever possible. Where images are held digitally, clients are also entitled to a copy.

13.16  Relevant clinical information should be provided promptly to colleagues taking over responsibility for a case and proper documentation should be provided for all referral or re-directed cases. Cases should be referred responsibly (Referrals and second opinions). Additional requests for information should also be dealt with promptly.

Retention, storage and destruction of clinical records  

13.17  Records should be kept secure and confidential at all times and there should be adequate back-up in place if records are stored electronically. 

13.18  The RCVS does not specify for how long clinical and client records should be retained and practices are free to set their own policies. Practices should however comply with any professional indemnity policy conditions relating to retention of records.

13.19  The record keeping requirements for Veterinary Medicinal Products (VMPs) are set out in the Veterinary Medicines Regulations (VMRs). Records of the retail receipt or supply (which includes prescribing and administration) of POM-V, POM-VPS and medicines prescribed under the cascade must be kept for 5 years. The Veterinary Medicines Directorate provides specific guidance on record-keeping requirements for veterinary medicines.

13.20  Records should be destroyed in a manner which safeguards against accidental loss or disclosure of content and protects client confidentiality. (Client confidentiality)

13.21  Where a practice intends to cease trading, clients should, where possible, be notified so they have an opportunity to obtain a copy of relevant clinical and client records if they choose to do so. Likewise, provision should be made to respond to requests for other veterinary surgeons to take over the case.

13.22  In some circumstances, the GDPR gives individuals a right of erasure (also known as the right to be forgotten). An individual is therefore able to request the deletion or removal of their personal data where, for example, (i) it is no longer necessary to retain the data for the purpose for which it was collected; (ii) the individual withdraws consent on which the processing was based and there are no other legal grounds for processing; (iii) the individual objects to the processing and there are no overriding legitimate grounds for the processing; or (iv) the data has been processed unlawfully. However the practice does not have to delete the data if it needs to keep it to comply with a legal obligation or to defend a legal claim.

Vaccination record cards

13.23  A vaccination record card held by the animal owner may be considered part of the clinical record and may be signed by a veterinary surgeon or a veterinary nurse (see supporting guidance 18.10 – 18.12). If a veterinary nurse signs the record, it is good practice to add the words ‘under the direction of ...’ and name the directing veterinary surgeon.

13.24  The animal should be identified on the vaccination record card and the principles set out in RCVS advice on identification of animals (see supporting guidance 21.30 – 21.33) should be followed. These state:

• 21.30  If an alleged identification mark is not legible at the time of inspection, no certificate should be issued until the animal has been re-marked or otherwise adequately identified.  
• 21.31  When there is no identification mark, the use of the animal's name alone is inadequate. If possible, the identification should be made more certain by the owner inserting a declaration identifying the animal, so that the veterinary surgeon can refer to it as 'as described'. Age, colour, sex, marking and breed may also be used.
• 21.32  The owner's name must always be inserted. (In the case, for example, of litters of unsold puppies this will be the name of the breeder or the seller.)
• 21.33  Where microchipping, tattooing or any other form of permanent identification has been applied it should be referred to in any certificate of identification. 

13.25  The animal may be presented to a different veterinary surgeon for a subsequent vaccination. To be useful, the vaccination record should be such as to allow the veterinary surgeon to identify the animal, if necessary, following any additional reasonable enquiries. Veterinary surgeons should not sign blank vaccination record cards.  

Vaccination reminders

13.26  In order to comply with the provisions of the GDPR, veterinary surgeons and veterinary nurses should only send vaccination reminders to clients where (a) clear and specific consent has been freely given, or (b) the client has provided a “soft-opt in”. Please see Chapter 23 for detail on this. This is because these reminders are likely to be considered to be marketing material. If the client withdraws their consent or opts out, further reminders should not be sent.