Practice Guidelines

Law, rules and regulations, not guidelines, specify the requirements for practice and violating them constitutes professional misconduct. Not adhering to these guidelines may be interpreted as professional misconduct only if the conduct also violates pertinent law, rules and regulations, some citations of which are listed at the end of these guidelines.

Guideline 5: Professional Practice

New York State licensed veterinarians and veterinary technicians should:

5.1
exercise the same care, skill and diligence in treating patients consistent with that of other members of the veterinary medical profession in good standing in the locality or community in which you practice, or in similar communities;

5.2
conduct your practice on the highest plane of honesty, integrity and fairness in dealing with your clients and patients;

5.3
disclose to clients any potential conflict of interest, (e.g., if you are providing services to both the buyer and seller of the same animal);

5.4
never make any attempt, directly or indirectly, to adversely influence the sound professional judgment of another veterinarian or veterinary technician;

5.5
not render any services or advice that could deceive or betray the public;

5.6
not issue a health certificate/certificate of veterinary inspection for any animal unless you have thorough knowledge, as a result of actual inspection and appropriate tests, that the animal meets the specifications and conditions certified;

5.7
treat all animals entrusted to you in keeping with professional standards of humane care and treatment; this includes the use of chemical restraint, sedation and pain management, when appropriate;

5.8
decide what medical or surgical cases you should accept in your professional practice; once you accept a patient, you should determine what course of treatment will be followed in consultation with the client;

5.9
advise the client regarding any treatment to be provided to the patient without using undue influence;

5.10
not allow any layperson, corporation, or other entity to control, influence, or exploit the relationship between the client/patient and the veterinarian;

5.11
establish a veterinary client/patient relationship, "VCPR," except when the client is unavailable. The VCPR exists when:
  1. you have sufficient knowledge of the animal to initiate at least a general or preliminary diagnosis of the medical condition of the animal. This means that you have recently seen and are personally acquainted with the care of the animal by a physical examination of the animal and/or by medically appropriate and timely visits with the animal; and
  2. you are readily available or have arranged for emergency coverage for follow-up evaluations in the event of adverse reactions or the failure of the treatment regimen.

5.12
only prescribe, deliver, or have delivered prescription drugs when a VCPR has been established and you have determined that the prescription drug is therapeutically indicated for the health and/or well being of the animal. You cannot fill prescriptions from other veterinarians.
  1. Written prescriptions can be filled at a pharmacy of the client's choice. A written prescription for a drug must be provided upon request if a valid VCPR has been established. All written prescriptions should include the following information:
    1. the name, address, telephone number, license number and signature of the prescribing veterinarian;
    2. the name and address of the client;
    3. the species and name, number or other identifying information for the animal;
    4. the name, strength and quantity of the drug(s);
    5. directions for use including, if applicable, withdrawal time;
    6. date of issue;
    7. number of refills; and
    8. Dispense as Written box.
  2. Drugs dispensed from a veterinary pharmacy should be labeled with the following information:
    1. name, address and telephone number of the facility;
    2. client's name;
    3. the species and name, number, or other identifying information for the animal;
    4. date dispensed;
    5. directions for use, including withdrawal time and precautionary information, if applicable;
    6. the manufacturer's trade name of the drug or the generic name, strength (if more than one dosage form exists), quantity of drug and the expiration date when established by the manufacturer; and
    7. name of prescribing veterinarian.
  3. Drugs should not be prescribed for a duration that is inconsistent with the patient's medical condition. The drug should not be prescribed for a period of more than one year from the date that you have examined the patient and prescribed the drug, unless you have conducted a subsequent examination of the patient and determined that there is a continued need for the prescribed drug.
  4. Childproof containers should be used unless otherwise requested by the client (an exception would be a drug that is prepackaged, for example, and dispensed with appropriate labeling).
5.13
not prescribe, dispense, deliver, or order any controlled substance unless you are currently registered with the Federal Drug Enforcement Administration (DEA). However, if you are not a veterinarian registered by the DEA but you are a DEA unregistered veterinarian employed by a DEA registered veterinarian you may dispense or administer controlled substances if the DEA registered veterinarian has knowledge that you are using the drugs in the usual course of your employment.

5.14
prepare a LEGIBLE individual record every time you provide professional services. The record can be written or computer generated, for each patient treated using accepted standard nomenclature (See Section 5.14E for food animal and colony practices).
  1. Records should be maintained for at least three (3) years after the animal's last visit. If controlled drugs were used to treat the animal, the record must be maintained for 5 years in accordance with DEA regulations.
  2. All medical record entries should be signed, initialed or otherwise validated by the individual making the entry.
  3. Adequate medical records should include all clinical information pertaining to the patient including sufficient information to justify the diagnosis and treatment. The medical record should include, but not be limited to, the following information:
    1. client identification (name, address, phone numbers);
    2. patient identification (species, breed, age, gender, reproductive status, colors and distinguishing markings, tattoo, microchip, etc.);
    3. patient history (past and recent history, current illness and chief complaint) which should include the dates of visits;
    4. results of physical examinations including weight, temperatures when possible, pulse rate, respiratory rate, mental status, conformation, hydration status, and complete systems review as appropriate to the circumstances;
    5. results of laboratory, imaging, and any other diagnostics performed as well as consulting specialist's reports;
    6. assessment, differential or definitive diagnosis;
    7. recommended treatment plan, including diagnostic recommendations, surgical procedures, any medical alternative, or other therapy discussed;
    8. written documentation of client's informed consent when appropriate for the treatment including acknowledgement of risk;
    9. treatments performed and therapy administered (including names, dosages, routes of administration of all drugs including anesthetics);
    10. results of treatments performed, when available and in the case of hospitalized patients, daily narratives of the patient's condition, assessment, changes in therapy and date of discharge;
    11. recommendations for outpatient care, follow up visits, postoperative instructions;
    12. all client communications either in person, via telephone or email;
    13. results of necropsies performed; and
    14. all other pertinent veterinary information.
  4. Daily treatment records, anesthesia logs, and surgical reports are all considered part of a patient's medical record.
  5. In a food animal or large colony practice where individual records might not be maintained, sufficient written information must be kept so that another veterinarian can continue veterinary services in a logical and professional manner.
  6. Medical records also include, but are not limited to:
    1. Radiographs
      1. Original radiographs are the property of the veterinary facility that originally ordered them to be prepared.
      2. Radiographs or copies should be released to the client or another veterinarian upon appropriate authorization of the client.
      3. Original radiographs should be returned to the veterinary facility that prepared them within reasonable time.
      4. Radiographs or copies of radiographs originating at an emergency hospital should become the property of the next attending veterinary facility upon receipt of the radiograph(s). Transfer of radiographs should be documented in the medical record.
      5. All exposed radiographic films, except for intra-oral radiographs, should have a permanent identification legibly exposed in the film emulsion. This identification should include the following:
        1. the hospital or clinic name and/or the veterinarian's name;
        2. client identification;
        3. patient identification;
        4. the date the radiograph was taken; and
        5. positioning information if relevant.
    2. Laboratory data is also part of the medical record.
  7. Emergency Clinic Medical Records
    The client should be provided with a legible copy of the medical record when the patient is released following emergency clinic service. The medical record should include at least the following:
    1. physical examination findings;
    2. dosages and time of administration of medications;
    3. copies of diagnostic data or procedures;
    4. all radiographs, or copies of radiographs, for which the facility should obtain a signed-release when transferred;
    5. surgical summary;
    6. tentative diagnosis and prognosis if known; and
    7. any follow-up instructions.
  8. Requests for copies of the medical record:
    Upon request, the client is entitled to copies of all of the medical records provided in a timely manner. A reasonable fee may be charged.
5.15
Anesthesia and surgery. You should use appropriate and humane methods of anesthesia (general or local), analgesia and sedation to minimize pain and distress during procedures. The veterinarian should comply with the standards listed below.
  1. Every animal should be given a physical examination within 24 hours before the administration of an anesthetic or as dictated by the animals condition. The results of the physical examination should be noted in the patient's medical records.
  2. Appropriate drugs and equipment to treat medical emergencies should be readily available.
  3. Supplemental heat for intra-op, post-op and critical care patients should be available when appropriate.
  4. Surgery should be conducted in an appropriate surgical environment at the level of practice commensurate with the practice of one's peers.

5.16
Compliance with OSHA requirements is required and a notebook of Material Safety Data Sheets (MSDS) should be kept and be readily available to all employees.

Previous | Contents | Next

Citations of Pertinent Law, Rules or Regulations:

Last Updated: June 4, 2009