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201 KAR 16:701.Standards for medical records.

RELATES TO:

KRS 257.080, 258.043, 258.065, 321.175, 321.181, 321.185, 321.187, 321.188, 321.200

STATUTORY AUTHORITY:

KRS 321.175, 321.187, 321.235(2)(b)3.c.

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;

(e)

Recommendations;

(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; and

4.

Materials used, including at a minimum:

a.

Suture materials;

b.

Mesh materials; and

c.

Other materials used; and

(h)

Any other pertinent details;

(5)

Laboratory reports;

(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:

(a)

Correction;

(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).

HISTORY: (50 Ky.R. 518, 1309, 1479; eff. 4-2-2024.)

FILED WITH LRC: December 11, 2023

CONTACT PERSON: Michelle Shane, Executive Director, Kentucky Board of Veterinary Examiners, 107 Corporate Drive, Second Floor, Frankfort, Kentucky 40601, phone (502) 782-0273, fax (502) 695-5887, email michelle.shane@ky.gov.

201 KAR 16:701.Standards for medical records.

RELATES TO:

KRS 257.080, 258.043, 258.065, 321.175, 321.181, 321.185, 321.187, 321.188, 321.200

STATUTORY AUTHORITY:

KRS 321.175., 321.187, 321.235(2)(b)3.c.

NECESSITY, FUNCTION, AND CONFORMITY:

KRS 321.175 establishes that~~states~~ the purpose of the Kentucky Veterinary Medicine Practice Act is to promote, preserve, and protect ~~the~~ public health, safety, and welfare. KRS 321.235(2)(b)3.c. authorizes~~allows~~ 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~~; it~~ is the point at which decisions about diagnosis and treatment are made, and during which care~~caring~~ 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. ~~A medical record shall be completed no more than forty-right (48) hours following the clinical encounter.~~

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; ~~and~~

(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.Section 2.

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.

(1)

~~The practice where the records were prepared shall be the official records custodian.~~

(2)

~~Original patient records shall be retained by the practice, veterinarian, or allied animal health professional (AAHP)AAHP~~ who prepared them and be readily retrievable for a period of five (5) years following the last patient encounter. Cessation from practice, either temporarily or permanently, does not relieve the practitioner from compliance with this section.

(3)

(a)

~~Records shall not be stored by a third party without a record of signed, informed consent by the client.~~

(b)

~~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)

(a)

The veterinarian or AAHP permittee may require that a request for medical records be in writing and may charge a reasonable fee for copying or the staff time in preparing the requested medical records.

(b)

~~In the event of a board investigation, no charges shall be authorized.~~

(c)

Copies of the medical records shall be provided to the client, designated veterinarian, AAHP permittee, or authorized representative within seven (7) calendar days after receipt of a proper request or sooner in accordance with the patient's medical condition.

(d)

~~Failure to provide the medical records in a timely fashion upon proper request shall be considered unprofessional conduct.~~

(5)

~~Pursuant to KRS 321.187(2), records shall be retained and accessible to the client for five (5) years past the date of the last clinical encounter with the patient.~~

Section 4.Section 3.

Veterinary medical records shall, at a minimum, include ~~the following information at a minimum~~:

(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;

(e)

Recommendations;

(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; ~~and~~

3.

Documentation of recovery; and

4.

Materials used~~and the amounts so used~~, including at a minimum:

a.

Suture materials;

b.

Mesh materials; and

c.

Other materials used; and

(h)

Any other pertinent details;.

(5)

Laboratory~~Radiographs, sonographic images, video recordings, photographs, or other imaging and laboratory~~ reports;

(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)(8)

The first and last name of the veterinarian, licensed veterinary technician, or veterinary assistant, or AAHP~~allied animal health professional (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; ~~and~~

(10)(9)

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~~When~~ 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.Section 4.

(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:

(a)

Correction;,

(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.Section 5.

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.Section 6.

Confidentiality of Records. Medical records shall be kept confidential in accordance with KRS 321.187(6).

(1)

Pursuant to KRS 321.187, an animal patient's medical record and medical condition is confidential and may not be furnished to or discussed with any person other than the client or other veterinarians, veterinary technicians, veterinary assistants, veterinary practice staff (including veterinary students, veterinary technician students, and special permittees), AAHP permittees, or consultants involved in the care or treatment of the patient, except upon written authorization of the client or under the following circumstances:

(a)

~~In response to a court order, or subpoena with notice given to the client or the client's legal representative;~~

(b)

~~For statistical and scientific research, if the information is abstracted in a way as to protect the identity of the patient and the client;~~

(c)

~~As part of an inspection or investigation conducted by the board or an agent of the board;~~

(d)

~~To verify the rabies vaccination status of an animal to law enforcement or local health department officials;~~

(e)

~~In the course of a consultation as defined in KRS 321.181(24) or provided for in KRS 321.200(1)(f);~~

(f)

~~In cases of animal abuse, pursuant to KRS 321.188;~~

(g)

Pursuant to KRS 321.185(4)(b)3., in cases of reportable diseases as they relate to public or animal health pursuant to KRS 257.080 and 258.065 and the administrative regulations promulgated under the authority of those chapters;

(h)

~~access to the records is specifically required by other state or federal law; and~~

(i)

~~Upon request by the board.~~

(2)

(a)

For purposes of written authorization from the client, nothing in this section shall require a veterinarian whose records are being authorized to be released to the client only to provide medical records, reports, and opinions to a client that may be used by a third party who does not have a veterinarian-client-patient relationship with the veterinarian for the purpose of, or in consideration of, the buying or selling of the animal.

(b)

~~A veterinarian taking radiographs of a patientfor an animal~~ ~~shall only be liable to the clientowner of the animal~~ ~~for the content of the record, and not liable to third parties for the purpose of buying or selling of the animal.~~

HISTORY: (50 Ky.R. 518, 1309, 1479; eff. 4-2-2024.)

FILED WITH LRC: December 11, 2023

Page Generated: 9/19/2024, 12:15:11 PM

Title 201 | Chapter 016 | Regulation 701

201 KAR 16:701.Standards for medical records.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

(c)

(d)

(e)

(f)

Section 2.

(1)

(2)

(3)

(4)

Section 3.

(1)

(2)

(3)

(4)

Section 4.

(1)

(2)

(3)

(4)

(a)

(b)

(c)

(d)

(e)

(f)

(g)

1.

2.

3.

4.

a.

b.

c.

(h)

(5)

(6)

(7)

(8)

(9)

(10)

(11)

(12)

Section 5.

(1)

(a)

(b)

(c)

(2)

(a)

(b)

(c)

(d)

Section 6.

(1)

(2)

Section 7.

201 KAR 16:701.Standards for medical records.

RELATES TO:

STATUTORY AUTHORITY:

NECESSITY, FUNCTION, AND CONFORMITY:

Section 1.

(1)

(2)

(a)

(b)

(c)

(d)

(e)

(f)

Section 2.