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

Rules

Rules relating to the Practising of Veterinary Professions: Amendment

Part V : Minimum standards for veterinary facilities

26. Records at veterinary facilities

 

 

(1) The attending veterinary professional shall maintain records for each animal or group of animals which are legible, accurate and permit prompt retrieval of information.

 

(2) Records shall, where applicable, contain the following information—
(a) client’s identification;
(b) patient name, other forms of identification, as well as the specie, breed, gender and age;
(c) clinical information;
(d) vaccination record;
(e) special procedures;
(f) diagnosis;
(g) treatment; and
(h) discharge instructions.

 

(3) Veterinary professionals attending to racing horses, excluding horses on spelling farms or studs registered with the National Horse Racing Authority of Southern Africa shall—

[Words preceding subrule (3)(a) substituted by section 11 of Notice 868 of 2009]

(a) complete a veterinary case sheet in duplicate containing the following information—
(i) premise identification;
(ii) patient identification;
(iii) diagnosis;
(iv) treatment; and
(b) Retain the original completed case sheet and hand a copy of the case sheet to the person requesting the treatment.

 

(4) All records including diagnostic images, laboratory and pathology results shall be retained by the principal of the veterinary facility for a period of three years from the patient's last visit.

 

(5) Records referred to in Rule 26(4) relating to a complaint, charge or allegation lodged with Council in terms of section 31(1) of the Act shall be presented to Council on request.

 

(6) Proper security arrangements shall be made to protect medical records from loss, fire, alterations or unauthorised use.

 

(7) Diagnostic images shall, on request of the owner of a patient or his/her representative, be handed over to such owner or representative, who shall sign a release in exchange for receipt of such records. Provided that a register be kept of the transfer indicating the date thereof as well as the particulars of the owner concerned.

 

(8)

(a) The principal of a veterinary facility will be responsible for confirming the identity of the attending veterinary professional to Council, where a complaint is lodged against his/her veterinary facility.
(b) Should the principal of a facility fail to comply with the provisions of Rule 8(a), he/herself will than be held accountable for any unprofessional conduct arising from such a complaint.

[Subrule (8) inserted by section 12 of Notice 868 of 2009]

 

[Notice 868 of 2009 makes reference in section 12 to the deletion of subrule (12) which does not appear to exist]