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
A VCPR exists when all of the following are satisfied:
  1. The veterinarian has assumed the responsibility for making medical judgments regarding the health of the patient with the assent of the owner of the animal or their duly authorized agent.
  2. The veterinarian has sufficient knowledge of the patient to initiate at least a general or preliminary diagnosis of the medical condition of the patient. This means that the veterinarian is personally acquainted with the keeping and care of the patient by virtue of:
    1. a timely examination of the patient by the veterinarian, or
    2. medically appropriate and timely visits by the veterinarian to the operation where the patient is managed, or
    3. medically appropriate and timely visits by the patient to the veterinary facility where the veterinarian is working.
  3. The veterinarian is readily available for follow-up evaluation and oversight of treatment and outcomes, or has arranged for appropriate continuing care and treatment.
  4. Patient records are maintained.

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 designated you to do so and you administer such substances under his or her direction and supervision [knowledge that you are using the drugs in the usual course of your employment].

5.14
General Medical Records Requirements

Veterinarians must prepare contemporaneous, permanent treatment records which reflect the actual treatment or services rendered. Such records should contain patient information regarding the examination, health assessment and/or treatment of the patient.

Medical records must be legibly and accurately written, complete, properly filed, retained and accessible in a manner that does not compromise the security and confidentiality of the records.

Each report, diagnosis, prognosis, and prescription made or issued by a corporation practicing veterinary medicine must bear the signature of one or more veterinarians who are in responsible charge of such report, diagnosis, prognosis, or prescription (Business Corporation Law § 1504 (c). A similar provision is in the Limited Liability Company Law requiring the same for professional service limited liability companies (Limited Liability Company Law § 1204(c)). In addition, the Electronic Signatures and Records Act (ESRA) provides that "signatures" made via electronic means are legally binding, just as hand-written signatures.

Veterinarians (or their practice) must establish, implement and monitor an effective system of author identification for medical records and/or medical orders to ensure the integrity of the authentication and protect the security of all transmissions, records and record entries.

Electronic medical records must include electronic signatures or computer-generated signature codes with date and time stamp for each entry. There must be an audit capability implemented to track access and edits by users.

Medical records must be adequate and retained for a period of three years from the date of treatment in accordance with Board of Regents Rules section 29.6 (a) (3). These records must be in their original or legally reproduced form.

Veterinary practices must ensure the confidentiality of patient records. Original medical records, information from or copies of records must be released only to or as authorized by the client or to individuals as permitted by Federal and State laws.

Content

The medical record must contain information to support the diagnosis, justify diagnostic testing, therapeutic interventions including surgery and hospitalization, and describe the patient's progress and response to medications and services.

All records must document, as appropriate, at a minimum the following:

  • Client identification and a description of the patient, including species, sex, age, breed, weight and individual identifying characteristics, which may include name or number;
  • Evidence of a physical examination, including a health history and a statement of the conclusion or impressions drawn;
  • A preliminary, working or final diagnosis, as appropriate to the case;
  • Results of all diagnostic tests including imaging or other assessment modalities performed on the patient;
  • Results of all consultative evaluations of the patient and findings by clinical staff or outside consultants involved in the care of the patient;
  • Properly executed consent forms for diagnostic testing, procedures and treatments;
  • All diagnostic and therapeutic orders, nursing documentation and care plans, reports of treatment, medication records, radiology, and laboratory reports, vital signs and other information necessary to monitor the patient’s condition;
  • Documentation of all complications, hospital acquired infections, and unfavorable reactions to drugs and anesthesia;
  • An assessment of the outcome of care and provisions for follow-up.
  • A summary of client communication including results of diagnostic intervention with differential or definitive diagnosis or revised plan based on client’s request for alternatives to recommendations.
  • Medical records for outpatient encounters, or information to justify admission and continued hospitalization and describe the patient's progress and response to medications and services, must be completed as soon as possible, but within 72 hours.
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.

5.17 Multi-doctor practice – guidance on supervision
Principals in veterinary practices – whether operating as sole proprietorships, partnerships (including professional limited liability partnerships), professional service corporations, or professional limited liability companies – are responsible for the environment under which doctors are employed to work.

The standard operating procedures by which the practice assigns and transfers responsibility for care—and the method in which this is reflected in the medical record—is the responsibility of the principals in the practice, regardless of the legal organization of the veterinary practice.

Principals are responsible for standard practice procedures. Among other matters, these procedures address medical recordkeeping, adherence to professional standards, and compliance with NYS statutes and regulations. Licensed veterinarians and veterinary technicians are accountable for the care they provide, but principals may be held liable when practice procedures compromise patient care or supervision of personnel.

To ensure adequate patient care and regulatory compliance, practitioners and clients must know who is responsible for the care of each patient at any time. This is especially critical for multi-doctor practices, specialty practices, and 24-hour facilities, where personnel shifts can make it difficult to know who is in charge of a given case. Failure to maintain clear lines of responsibility can blur accountability and lead to poor patient care and client uncertainty.

The practice’s medical records must clearly identify the treating veterinarian for each visit. Likewise, if a patient is admitted, the veterinarian who is responsible for the overall care of the patient must be identified. The responsible veterinarian may provide care through the supervision of other appropriate personnel, but that individual is accountable for any complaints that may arise about the quality of supervision.

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Citations of Pertinent Law, Rules or Regulations:

Last Updated: April 16, 2021