VETERINARY MEDICINE & SURGERY/TEACHING HOSPITAL AUTHORIZATION NO. 37-417

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  1. Medical Records: Patient Charts
  2. Medical Records: Ambulatory Files

 

ITEM NUMBER

1. Medical Records: Patient Charts

These records document services rendered and charges made for services rendered to animals seen by clinical personnel of the UMC Veterinary Medicine & Surgery/Teaching Hospital. All animals are seen on one of four services: small animal (pets), large animal, equine, or by visit to farm site. Charts may include, but not limited to, 1) hospitalization agreement form, signed by client (owner or agent), allowing University permission to perform treatments and stating client’s agreement to pay charges incurred; 2) medical history form; 3) physical examination form and problem sheet; 4) progress record providing, on a daily basis, record of patient’s treatments, notation of medicines administered, laboratory examinations performed; 5) report on findings of laboratory examinations; 6) surgery report providing narrative description of surgery performed; 7) record of anesthesia; 8) post-operative/intensive care unit instructions; 9) discharge summary and client instruction sheet summarizing animal’s condition and treatments, if any, for client to administer; 10) daily charge record, itemizing all charges made for treatments, medications, etc.; 11) patient summary and charge sheet providing brief summary information on animal and client; 12) report of Necropsy Laboratory, if animal died and necropsy was preformed; 13) correspondence between staff of Veterinary Hospital and client or referring veterinarian.

Authorized Retention:

Retain for three (3) years after date of patient’s last visit, except if animal is deceased, retain chart for six (6) months after death, then destroy, provided a microfilm/imaged copy has been made in either/both cases.

NOTE: Imaged records, retained for fifteen (15) years, and review retention schedule for revisions in five (5) years after Veterinary Hospital’s imaging system is up and running.

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2. Medical Records: Ambulatory Files

These records consist of forms documenting visits to farm sites, showing client name, breed of animal, ailment, diagnosis, treatments given, and charges made. Some parts of this information may be used as research material.

Authorized Retention:

Retain for seven (7) years after date of creation, then destroy.

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Supersedes Records Retention Authorization 79-03.

Reviewed 2012-08-03.