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Veterinary and Para-Veterinary Professions Act, 1982 (Act No. 19 of 1982)

Rules

Rules relating to the Practising of Para-Veterinary Profession of Veterinary Nurse

13. Records at veterinary nursing facility

 

(1) The veterinary nurse must maintain records, for each animal or group of animals which are legible, accurate and permit prompt retrieval, if and when necessary.

 

(2) Records must contain the following information for individual animals as applicable—
(a) The date or period of the examination or consultation;
(b) Name of the veterinarian who treated the patient and the referral letter;
(c) Client’s identification;
(d) Patient name, other forms of identification, as well as the species, breed, gender and age;
(e) Clinical information for the purposes of continuous care and assessment;
(f) Vaccination record;
(g) Special procedures;
(h) Problem attended to and/or diagnosis made by the attending veterinarian;
(i) Treatment and scripts issued by the veterinarian; and
(j) Discharge instructions.

 

(3) All records referred to in Rule 14(2) must be retained by the principal of the veterinary nursing facility for a period of five years from the patient’s last visit.

 

(4) Records referred to in Rule 14(4) relating to a complaint, charge or allegation lodged with Council in terms of section 31(1) of the Act must be presented to Council within seventy-two (72) hours of being requested to submit such records, or as otherwise arranged with Council.

 

(5) Proper security arrangements must be made to protect records from loss, fire, alterations, additions, supplements or unauthorised use; electronic records must be backed up on a daily basis and electronic backups should be stored off-site.

 

(6) Any alterations, additions and/or supplements to any records must be entered as a supplement to said record and must be dated and clearly defined as such.

 

(7)

(a) The principal of a veterinary nursing facility will be responsible for confirming the identity of the attending veterinary para-professional to Council, where a complaint is lodged against his/her veterinary nursing facility.
(b) The principal of a veterinary nursing facility will be responsible for providing the records referred to in Rule 6(5), should a complaint be lodged against the professional no longer in the employ of the principal of the facility, subsequent to the date on which the complaint originated.
(c) If the principal of a facility fails to comply with the provisions of Rule 15(7)(a) he/she will be held accountable for any unprofessional conduct arising from such a complaint.