Louisiana Administrative Code › Title 46 - PROFESSIONAL AND OCCUPATIONAL STANDARDS › Part LXXXV - Veterinarians › Chapter 7 - Veterinary Practice › Section LXXXV-701 - Record Keeping

Current through Register Vol. 50, No. 6, June 20, 2024
A. It shall be
				considered unprofessional conduct within the meaning of
				R.S.
				37:1526(14) for a licensed
				veterinarian to keep improper records. The purpose of these regulations is to
				produce a record such that a veterinary peer can, by using said records, gain a
				full understanding of the findings, diagnostic process, reasons for treatment
				protocol, and applicability of surgical procedures. Records shall be legible,
				and established and maintained as follows.
1.
				Each Louisiana licensed veterinarian shall maintain an individual written, or
				computer generated, record on each animal or herd to include identification of
				animal or herd, diagnosis of illness, disease or condition and treatment
				provided, progress notes and reassessment, and discharge summary, as follows.
a.
i.Identification of the animal or herd shall
				include the breed, sex, description or permanent identification (if available),
				tattoos or other identifying marks, and the name and address of the owner.
ii. Diagnosis of illness, disease
				or condition shall document the animal or herd's history, signs, symptoms,
				complaints, objective tests such as radiographs and laboratory results, and the
				veterinarian's interpretation of examination findings, as well as intended
				goals and treatment including surgical procedures and/or drug therapy. Drug
				therapy shall include the names of legend drugs, controlled substances and/or
				over-the-counter (OTC) products as set forth below; the date and amount
				administered, prescribed or dispensed; and the method of
				administration.
iii. A progress
				note shall document the animal or herd's subjective status, changes in
				objective findings, and progression or regression of goals and treatment. A
				progress note shall be documented for each visit, for continuation of
				treatment, for the particular diagnosed illness, disease, or
				condition.
iv. Reassessment shall
				include all elements of a progress note, as well as a revision of the treatment
				plan as indicated. A new diagnosis of illness, disease or condition may be
				warranted. Reassessment shall only be performed by the veterinarian.
				Reassessment, including a new diagnosis of illness, disease, or condition when
				applicable, shall be documented at the time such is performed.
v. Discharge summary shall document the
				reasons for discontinuation of care, degree or goal of achievement, and a
				discharge plan, if required, which shall only be documented and signed by the
				attending veterinarian.
vi. The
				documentation standards set forth above do not mandate a particular format,
				however, a record must include these elements, as well as any other document
				required by law or the board's rules. Examples include General Anaesthesia
				Consent Forms, Euthanasia Consent Forms, documents involving prescribing,
				administering, or dispensing legend drugs or controlled substances, and billing
				invoices or statements of services or products provided. The veterinarian shall
				be ultimately responsible for the content and maintenance of the record.