<?xml version='1.0' encoding='utf-8'?>
<regulation prefix="Regulation" num=".10" citation="COMAR 15.14.01.10" title_num="15" subtitle_num="14" chapter_num="01" heading="Record Keeping.">
  <paragraph num="A.">
    <text>For animals that a veterinarian treats, the veterinarian shall prepare a legibly written record that accurately and thoroughly reflects the treatment provided. At a minimum, the veterinarian's record shall include the following information, as applicable:</text>
    <paragraph num="(1)">
      <text>If available, the name, address, and phone number of the animal's owner;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If available, the name and identity of the animal;</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If available, the age, sex, and breed of the animal;</text>
    </paragraph>
    <paragraph num="(4)">
      <text>The dates (beginning and ending) of custody of the animal;</text>
    </paragraph>
    <paragraph num="(5)">
      <text>A short history of the animal's condition as it pertains to the animal's medical status;</text>
    </paragraph>
    <paragraph num="(6)">
      <text>The animal's physical condition at the beginning of custody and the initial diagnosis, if any;</text>
    </paragraph>
    <paragraph num="(7)">
      <text>The animal's condition, as evidenced through a physical examination, not more than 12 hours before administration of one of the following:</text>
      <paragraph num="(a)">
        <text>Anesthetic;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Injectable sedative; or</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Injectable tranquilizing agent.</text>
      </paragraph>
    </paragraph>
    <paragraph num="(8)">
      <text>The treatment provided the animal and if medication is given, the following shall be provided:</text>
      <paragraph num="(a)">
        <text>Amount in milligrams or the volume and concentration of substance used;</text>
      </paragraph>
      <paragraph num="(b)">
        <text>Frequency; and</text>
      </paragraph>
      <paragraph num="(c)">
        <text>Route of administration;</text>
      </paragraph>
    </paragraph>
    <paragraph num="(9)">
      <text>The progress and disposition of the case; and</text>
    </paragraph>
    <paragraph num="(10)">
      <text>The surgery log and anesthetic log, if any.</text>
    </paragraph>
  </paragraph>
  <paragraph num="B.">
    <text>The veterinarian shall record the information referenced in §A of this regulation in a timely manner, that is, as soon as practicable after the veterinarian has seen the animal.</text>
  </paragraph>
  <paragraph num="C.">
    <text>If the veterinarian discovers that the record is incomplete or in error, the veterinarian shall amend the record, being sure to date and initial the amendment.</text>
  </paragraph>
  <paragraph num="D.">
    <text>A veterinarian shall label each radiograph and any other diagnostic image or picture with the hospital, clinic, or veterinarian's name, the patient's name, the owner's name, and the date the image or picture was taken.  Diagnostics include, but are not limited to, the following:</text>
    <paragraph num="(1)">
      <text>Ultrasound;</text>
    </paragraph>
    <paragraph num="(2)">
      <text>Magnetic resonance imaging (MRI);</text>
    </paragraph>
    <paragraph num="(3)">
      <text>Computed tomography (CT) scans; and</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Any other device that is used to generate an image of a patient.</text>
    </paragraph>
  </paragraph>
  <paragraph num="E.">
    <text>Patient records shall be kept by a veterinarian for 3 years after a patient's last visit.</text>
  </paragraph>
  <paragraph num="F.">
    <text>Patient Records.</text>
    <paragraph num="(1)">
      <text>Patients' records are the property of the veterinary practice for whom the records were made.</text>
    </paragraph>
    <paragraph num="(2)">
      <text>If requested by a patient's owner, the veterinarian shall release a copy of an animal's written record to the owner or a subsequent treating veterinarian. The veterinarian may require the owner to pay the reasonable cost of providing the records requested.</text>
    </paragraph>
    <paragraph num="(3)">
      <text>If requested by a patient's owner, the veterinarian shall release temporarily to a subsequent treating veterinarian the original nonwritten record of the animal, such as, but not limited to, radiographs, photographs, electrocardiograms, and slides. The subsequent treating veterinarian shall return these original nonwritten records within 30 days of their receipt or such other time as agreed to by the parties.</text>
    </paragraph>
    <paragraph num="(4)">
      <text>Upon request and if known, a veterinarian shall inform a boarding facility, including a veterinary hospital offering boarding services, which is boarding a veterinarian's patient, whether the animal's vaccinations are current.</text>
    </paragraph>
  </paragraph>
  <paragraph num="G.">
    <text>The requirements of this regulation apply to companion pet animals only.</text>
  </paragraph>
</regulation>