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I keep a separate record for each animal.
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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.
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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.
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I obtain and record informed consent for all treatment provided.
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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.
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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.
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My entries are legible, accurate, made in chronological order and clearly dated.
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My entries are made at the time of the appointment, or as soon thereafter as practicable.
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Any corrections I make to records do not remove the original information, and any corrections or additions are initialled/signed.
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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.
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I don’t make subjective or emotive comments; all information is professional. I know that clients have a right to access their records.
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All treatment and entries in the record are made with my regulator’s professional standard in mind.
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I keep an appropriate, consistent standard of records for all animals, not just those with complex needs.
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I know that I cannot delegate responsibility for the accuracy of information recorded to another person.
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My records are stored securely and in a way that ensures they can be promptly retrieved.
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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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