Nevada Administrative Code › Chapter 638 - Veterinarians › PROFESSIONAL AND ETHICAL STANDARDS › Section 638.0475 - Maintenance and availability of records; required contents of records; cessation of practice without providing for continuation of treatment

Current through June 11, 2024
1. Each licensed veterinarian shall maintain
			 in this State for at least 4 years a separate medical record of each animal
			 receiving veterinary services, including, without limitation, an examination
			 conducted pursuant to NAC
			 638.610, from the licensed
			 veterinarian or under his or her supervision. The records must be available for
			 inspection by the Board or its representative or the owner of the animal during
			 normal business hours at least 5 business days each week. Except as otherwise
			 provided in this subsection, the licensed veterinarian shall provide a copy of
			 that record to the Board or its representative or the owner of the animal
			 receiving veterinary services not later than 5 business days after receiving a
			 request from the Board or its representative or the owner of the animal. The
			 licensed veterinarian is not required to provide a copy of any radiographs or
			 other diagnostic images in the medical record to the owner of the animal
			 receiving veterinary services.
2.
			 Except as otherwise provided in subsection 10, the medical record must contain
			 the following information, in legible form:
(a) The name, address and telephone number of
			 the animal's owner;
(b) The name or
			 identifying number, or both, of the animal;
(c) The age, sex, weight and breed of the
			 animal;
(d) The dates of care,
			 custody or treatment of the animal;
(e) Documentation of the informed consent of
			 the client for medical treatment of the animal;
(f) A short history of the animal's condition
			 as it pertains to the animal's medical status;
(g) The results of and notations from an
			 examination of the animal, including, without limitation, the temperature,
			 pulse and respiration rate of the animal and laboratory data pertaining to the
			 animal;
(h) The diagnosis or
			 condition at the beginning of custody of the animal, including, without
			 limitation, results of tests;
(i)
			 The immunization record of the animal;
(j) All clinical information pertaining to
			 the animal, including, without limitation, sufficient information to justify
			 the diagnosis or determination of the medical status of the animal and to
			 warrant any treatment recommended for or administered to the animal;
(k) The notes taken during surgery,
			 including, without limitation:
(1) The name
			 and quantity of any drug administered for anesthesia and
			 preanesthesia;
(2) The procedure
			 performed;
(3) The times at which
			 the surgery begins and ends;
(4) If
			 the surgery is performed in a veterinary facility using general anesthesia:
(I) The vital signs of the animal at the
			 beginning and end of the surgery that are appropriate to the species and
			 condition of the animal at the time of surgery, which may include, without
			 limitation, the temperature, pulse, heart rate, respiration, blood pressure,
			 capillary refill time and oxygen levels of the animal;
(II) The vital signs of the animal recorded
			 at least every 5 minutes during the surgery, including, without limitation, the
			 pulse, heart rate and respiration of the animal; and
(III) If any of the information required
			 pursuant to this subparagraph is generated by an automated device, an
			 indication that the information generated by the automated device was regularly
			 reviewed and analyzed by a veterinarian, veterinary technician or veterinary
			 assistant during the surgery;
(l) Any medication and treatment
			 administered, including, without limitation, the amount and
			 frequency;
(m) The progress and
			 disposition of the case;
(n) The
			 name of each person who is not an employee of the veterinarian who provided
			 professional advice or performed treatments, examinations or other services
			 pertaining to the animal;
(o) The
			 signature, initials or other identifying mark of the person who made the entry
			 in the medical record;
(p) Any
			 radiographs other than intraoral dental radiographs. Each radiograph other than
			 an intraoral dental radiograph must be labeled on the image as follows:
(1) The name of the veterinarian or facility
			 that took the radiograph;
(2) The
			 name or identifying number, or both, of the animal;
(3) The name of the animal's owner;
(4) The date on which the radiograph was
			 taken; and
(5) The anatomical
			 orientation depicted by the radiograph; and
(q) Any intraoral dental radiographs or other
			 diagnostic images. For each intraoral dental radiograph or other diagnostic
			 image, the medical record must include the information set forth in
			 subparagraphs (1) to (5), inclusive, of paragraph (p) with regard to the
			 intraoral dental radiograph or other diagnostic image. That information may be
			 included:
(1) In a hard copy of the medical
			 record if the medical record is maintained as a written record; or
(2) In the computer file which contains the
			 intraoral dental radiograph or other diagnostic image if the medical record is
			 maintained as a computer record.