Have you ever tried to read an instruction manual and thought, “I can’t make sense of this — is it upside down or in another language?” You’re not alone! Everything seems to have a manual that’s difficult to understand, and our pets are no exception. In this case, their “manuals” are their medical records. These documents provide you and your veterinarian with a lot of essential information to help your pet live their best life.
Your pet’s medical record is a confidential and legal record that systematically details their entire health history, just like your personal medical record. It’s used to provide information, including the assessment, diagnosis, and treatment resulting from all of your pet’s veterinary visits. It can be helpful for you, current and future veterinary team members, and others.
Medical records generally contain:
Client’s Contact Information
This includes your name, address, phone number(s), and e-mail address. It’s critical to keep this information current.
Pet’s Signalment
This is a description of your dog or cat, including species, breed, coat color, distinguishing markings, age, date of birth, and reproductive status (spayed/neutered or intact). It may also include microchip information. When your pet is in a clinic full of other cats and dogs, it’s good to have a clear physical description in their records. Some practices also include a photograph of your pet for identification purposes. If your pet is ever lost or stolen, this can also come in handy.
Pet’s Medical History
These records ensure that all the medical professionals working with your dog or cat have the same detailed information on their assessments, vaccination history, past and current treatment plans, past and current medications, test results, weight history, and more. Some of it may be a bit too technical for the layperson, but your veterinarian can answer any questions you have.
Surgical History
This section is particularly important if you’re working with your veterinarian and an outside medical professional (such as a specialist veterinary surgeon or physical therapist) for a procedure. It ensures everyone caring for your pet is on the same page with things like the initial diagnosis, surgical recommendations, relevant test results, discharge instructions, and recovery plans. If, for example, your dog or cat is referred to a specialist for post-op physical therapy, they’ll refer to this section to best plan your pet’s care. Also, if your pet ever has an issue later in life related to a past surgery, their current veterinarian will benefit greatly from reviewing the specifics of that surgery from years earlier.
All pet medical records are the property of the veterinary hospital. The general law for most states is that records must be kept for 3 to 5 years after the patient’s last exam or treatment. This is why, as we’ll discuss later, you should have your own copy that spans your pet’s entire life.
The veterinary hospital may assess a reasonable charge for the search, retrieval, duplication, and mailing of the records — another reason having your own copy is helpful. These records can only be released with your consent or court order because they are confidential and privileged.