Content of Animal Health Record – Best Practice

Introduction

Veterinary medical records are far more than just paperwork — they are a professional and legal obligation that underpins high-quality animal care. Keeping thorough, clear, and accurate records is a requirement under multiple pieces of legislation and guidelines, including the Veterinary Practice Acts across Australia and specific professional standards like Guideline 7 and the WA Clinical Record Guidelines.

This free online course helps veterinary professionals (vets, nurses, and practice managers) understand the correct content, structure, and expectations of a high-standard animal medical record. It draws on published guidelines and real-world examples to ensure that veterinary practices meet their ethical, clinical, and regulatory obligations.

Module 1: Purpose of Veterinary Medical Records

Veterinary records must:

Clearly identify the animal
Justify diagnosis, treatment, and management decisions
Document informed discussions with the owner or authorised person
Enable another veterinary professional to take over the animal’s care seamlessly
Comply with legal obligations for medications, including controlled substances
Provide evidence in case of audits, complaints, insurance claims, or legal matters

A well-kept record protects both the animal and the practitioner.

Module 2: Essential Record Content – What to Include

Each clinical entry should include:

Date of consultation or treatment
Owner’s details: name, address, phone number
Animal identifiers: name, species, breed, sex, age, colour, microchip/tag
Presenting the complaint and history from the owner
Physical examination findings, including normal and abnormal findings
Diagnostic tests ordered and results (if available)
Diagnosis – whether working, provisional, or confirmed
Treatment plans, including alternative options, were discussed
Risks, costs, and limitations explained to the owner
Owner’s choice and documented reasoning
Consent forms, including informed consent and financial consent
Medication details:
- Name of the drug (especially scheduled substances)
- Dose, duration, and withholding periods (if food-producing animals)
Procedures performed
Progress notes for hospitalised animals
Discharge instructions
Follow-up or referral plans

Module 3: Format and Timing – When and How to Write

Records must be:
- Legible
- Complete
- Accessible
- Created at the time of service or as soon as possible afterwards
For handwritten records:
- Corrections should be dated, timed, and initialled
For electronic records:
- Corrections must be added as new entries, not overwriting originals

Backups of digital records must be made at least daily and stored securely off-site.

Module 4: Supporting Documents in the Record

Attach or upload into the clinical record:

Laboratory reports
Radiographic images and reports
Surgical and anaesthetic notes
Referral or specialist reports
Veterinary certificates
Photographs (if relevant)
Necropsy reports
Dental records
Hospitalisation charts
Communication logs

These documents provide additional context and legal strength to your clinical notes.

Module 5: Special Situations

Food-producing animals: Always note the appropriate withholding periods for meat, milk, eggs, etc.
Controlled substances (S8 drugs):
- Comply with both veterinary and State drug laws
- Log usage in the S8 register
- Maintain accurate records of quantity, dosing, and use
Wildlife and stray animals: Maintain clinical notes even if the owner is unknown or undefined
Insurance claims and referrals: Provide a copy of the record upon written request (except if there is a valid reason not to – which must be documented)

Module 6: Privacy, Ownership, and Access to Records

Veterinary records are the property of the clinic, but:
- Owners are entitled to a copy or summary upon request
- You may charge a reasonable fee for printing or preparation
Disclosure of records is permitted:
- To the owner or their representative
- To other veterinary professionals (with consent)
- When required by law, regulatory bodies, or court orders
Always keep a record of:
- Who accessed the file
- What was released
- To whom it was sent

Module 7: Efficiency Tips for Record Keeping

Use structured templates with dropdowns or checklists where possible
Record information during or immediately after the consultation
Use voice-to-text or shorthand tools for faster entry (if legally allowed)
Document even normal findings to demonstrate thorough examination
Use phrases such as:
- “All findings within normal limits”
- “Owner declined further diagnostics after risks and costs were explained”
- “Consent form signed prior to procedure”

Module 8: Consequences of Poor Record Keeping

Failing to maintain adequate records may result in:

Disciplinary action by the Veterinary Board
Legal liability in case of animal injury, death, or client complaint
Breach of legislation (especially around drug use)
Loss of insurance cover or difficulty defending claims

Good records are your best defence — always write as if your notes will be reviewed in court or by a regulatory board.

Conclusion and Certification

Veterinary records are the foundation of professional care. They must be accurate, timely, detailed, and legally compliant.

On completing this course, you will receive a Certificate of Completion which can be included in your continuing professional development (CPD) portfolio. This course supports best practice across all veterinary care settings and helps practices meet their regulatory and ethical obligations.

Course Delivery

Fully Online: Participants can access the course content at any time from any device connected to the internet.

Technical Requirements

Device Requirements: Access to a computer or mobile device with internet connectivity.

Certification

Certificate of Completion: After reviewing all course sections, participants can download a certificate to encourage participation and acknowledge their learning.