Record keeping checklist - Veterinarians

Maintaining appropriate and proper clinical records relies on veterinarians integrating fundamental record keeping practices into their daily routines. Using this checklist will help to evaluate your practice. ‘No’ answers are opportunities for improvement.




I keep a separate record for each animal.

I record sufficient information to allow me or someone else to return to the record at any time and be able to understand what took place and why. 

Where the most ideal treatment option isn’t consented to by the client, I make a note in the record why this treatment wasn’t provided.

I obtain and record informed consent for all treatment provided.

If documents are scanned to the record, such as external reports, the scanning is done to a sufficient quality that retains the legibility and detail of the original document.

I have consistent processes for recording the details of any further interactions with clients that may occur via telephone, text message, email or other method. 

My entries are legible, accurate, made in chronological order and clearly dated. 

My entries are made at the time of the appointment, or as soon thereafter as practicable.

Any corrections I make to records do not remove the original information, and any corrections or additions are initialled/signed.

I only use abbreviations that are widely recognised and accepted in my profession or I provide a list of abbreviations in the animal’s file.

I don’t make subjective or emotive comments; all information is professional. I know that clients have a right to access their records.

All treatment and entries in the record are made with my regulator’s professional standard in mind.

I keep an appropriate, consistent standard of records for all animals, not just those with complex needs.

I know that I cannot delegate responsibility for the accuracy of information recorded to another person.

My records are stored securely and in a way that ensures they can be promptly retrieved. 

My records are collected, maintained, transferred and disposed of in accordance with federal privacy laws as well as other relevant state or territory laws, codes and guidelines.

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