1. (a) Each veterinary medical facility shall comply with the following.

2. (b) Medical records.

   1. (1) A legible individual record shall be maintained for each companion animal.

   2. (2) However, the medical records for a litter may be recorded either on the dam’s record or on a litter record until the individual animals:

      1. (A) Are permanently placed; or
      2. (B) Reach the age of three (3) months.
   3. (3) Records for herd or flock animals may be maintained on a group or client basis.
3. (c) All records shall be readily available and must be kept for a period of three (3) years following the last treatment or examination.

4. (d) Animal health records shall be the property of the owner or manager of a veterinary practice that has prepared such record and shall include, but are not limited to:

   1. (1) Written records and notes;
   2. (2) Computer-generated records;
   3. (3) Radiographs;
   4. (4) Sonographic images;
   5. (5) Video tapes;
   6. (6) Photographs;
   7. (7) Laboratory reports; or
   8. (8) Other diagnostics or case management information received as the result of consulting with other licensed veterinarians or medical specialists.

5. (e)

   1. (1) Medical records shall be maintained in a manner that will permit any authorized licensed veterinarian to proceed with the care and treatment of the animal, if required, by reading the medical record of that particular patient.
   2. (2) The record shall clearly explain the initial examination.

6. (f) Patient records shall include, but are not limited to, the following information:

   1. (1) Name and/or initials of the veterinarian responsible for entries;
   2. (2) Name, address, and telephone number of the owner and/or client;
   3. (3) Name of patient, number or other identification of the animal and/or herd or flock;
   4. (4) Species, breed, age, sex, color, and distinctive markings;
   5. (5) Pertinent history and presenting complaint;

   6. (6) Physical examination findings to include:

      1. (A) Temperature;
      2. (B) Weight;
      3. (C) Body condition;
      4. (D) Respiration;
      5. (E) Pulse;
      6. (F) Eyes;
      7. (G) Ears;
      8. (H) Nose and throat;
      9. (I) Oral cavity;
      10. (J) Respiratory system, including auscultation of the thorax;
      11. (K) Palpation of the abdomen;
      12. (L) Lymph nodes; and
      13. (M) Evaluation of musculoskeletal, neurological, genito/urinary systems;
   7. (7) Assessment/diagnosis, treatments and intended treatment plan, medications dispensed or prescribed, immunizations administered, dosages, strength, frequency, and route of administration;
   8. (8) Surgical procedures shall include a description of the procedure, name of the surgeon, type of sedative/anesthetic agent or agents used, dosage, strength, and route of administration;
   9. (9) Dated progress of the case while in veterinary medical facility, and if relevant, a prognosis of the animal’s condition;
   10. (10) Exposed radiographs shall have permanent facility and animal identification;
   11. (11) If the temperament of the animal precludes any exam or test or if a client waives or declines any examination, test, or other recommended treatments, such notation of denial or signed waiver shall be included in the medical record;
   12. (12) All consent statements, surgical, or treatment consent forms should be included in the medical record;
   13. (13) If there are any discharge instructions, they should be noted on the medical record; and

   14. (14) Name of any person (other than the veterinarian’s own employees):

       1. (A) Furnishing professional advice; or
       2. (B) Performing treatments, examinations, or other services.

7. (g) Medical records for large animal facilities/practices shall be clear, legible, retrievable, and maintained on either a herd (flock) or individual basis and contain:

   1. (1) Name and initials, business/farm name, address, and phone number of the owner/agent;

   2. (2) Relevant medical and surgical procedures (including vaccinations given and lab reports) to the:

      1. (A) Individual;
      2. (B) Group; or
      3. (C) Herd; and
   3. (3) A record of all drugs administered or dispensed, including quantity and withdrawal times.

8. (h)

   1. (1) A radiograph is the property of the veterinarian who originally ordered it.
   2. (2) It shall be released upon the request of another veterinarian, and such radiograph shall be returned to the veterinarian who originally ordered it to be prepared within a reasonable time.

Codification Notes: This section as promulgated prior to codification into the Code of Arkansas Rules provided the following at the beginning of the section: “(Adopted: 6/23/1993) (Amended: 11/12/2008) (Effective: 1/1/2009)”.