Veterinarians’ Record-Keeping Requirements in Germany: What Must Be Recorded and How Long Records Must Be Retained

In Germany, the obligation to document examinations, treatments, and medications is called the “Dokumentationspflicht.” It stems from several different sets of regulations, and it’s easy to overlook some aspects of it when you have a full schedule of patients. Here, we’ll go over where the requirements come from, what needs to be documented, and how you can meet them without letting medical record-keeping take up your evenings.

The General Obligation to Keep Records

One example is the professional code of the Bremen Veterinary Association, published in the state’s official gazette in 2016. According to Section 3 of that code, veterinarians are required to keep records of the findings they make and the measures they take in the course of their professional practice and to retain them for five years, unless another time limit applies. This requirement also applies to technical documentation.

The licensing requirements are determined by each state’s veterinary board, so be sure to check the regulations in the state where your practice is located.

Notes on Medications

According to Section 15 of the Regulation on Veterinarians’ In-House Pharmacies (Tierärztliche Hausapothekenverordnung, TÄHAV), veterinarians must keep records of the purchase and dispensing of prescription veterinary drugs, and the same applies to certain other drugs and products. A well-organized collection of delivery notes, invoices, or packing slips serves as documentation of purchases. According to the regulation, records in the practice log or patient records specifically serve as documentation of dispensing and use. Upon request by the authorities, these records must be presented, organized by animal owner.

How to Take Notes

According to Section 16 of TÄHAV, prescriptions and notes must be recorded in a clear, understandable, and chronological manner. They may be recorded and stored electronically, but in that case, it must be ensured that the information can be accessed at any time throughout the entire period it is to be retained.

How long the notes are saved

TÄHAV does not specify its own retention period in years. According to Section 16 of the regulation, the time limit specified in Article 103(5) of EU Regulation (EU) 2019/6 on veterinary medicinal products applies, and after that time limit, the data must be deleted when it is no longer needed.

The Gap Between Expectations and Everyday Life

What’s usually missing from a note is information the veterinarian knows but didn’t have time to write down. The medical history becomes brief when the visit runs long, and what was said about follow-up never makes it into the medical record. A fixed structure makes it easier to see what’s missing. Many clinics use SOAP, where the note is divided into subjective data, objective findings, assessment, and plan; how this structure works in veterinary medical records is described on the page about SOAP records for veterinarians.

Here's how Vetz helps with record-keeping

Vetz listens during the conversation with the pet owner and creates a structured draft medical record based on the practice’s own templates. Within seconds of the conversation, you’ll have a draft with accurate medical terminology, and Vetz can highlight any missing information, such as the patient history or diagnosis. Learn more about this approach on the page about AI-powered medical record-keeping.

With active integration, the completed medical record is transferred to the practice’s medical record system, ensuring that the note ends up in the right place without anyone having to copy it. Vetz integrates with Provet Cloud, Vettigo, and MHK FileMaker, and the article on Vetz and your medical record system describes how the integration works.

As the veterinarian, you are always the one who reviews, revises, and signs the note. The draft from Vetz is intended to assist you, and the responsibility for ensuring the accuracy of the medical record remains with you.

Data Protection for Medical Records

Medical records contain information about pet owners and are therefore subject to the GDPR. The article on AI and the GDPR for veterinarians outlines what practices should keep in mind, and more information about Vetz’s security measures is available on the security page. Ask each vendor where the data is stored, which subprocessors are used, and how long the data is retained.

Learn more about Vetz

Would you like to see how Vetz can simplify medical record-keeping at your practice? Book a demo, and we’ll show you how Vetz creates draft medical records using your templates and transfers them to your medical record system.