Record-Keeping for Veterinarians: Rules, Content, and How to Keep Up with Your Records

The medical record is the veterinarian’s most important tool after the examination itself. It should be understandable to a colleague who takes over the case and stand up to scrutiny should it ever be reviewed. Here, we’ll go over what the regulations say about record-keeping in animal health care and how you can keep your records complete without having to spend your evenings on them.

Who Is Responsible for Keeping Records

According to Chapter 2, Section 1a of the Act (2009:302) on Activities in Animal Health and Medical Care, animal health personnel must maintain records of animal health care and medical treatment. The Act defines animal health personnel as persons who engage in animal health and medical care and who hold a license, approval, or special permit to practice the profession, or who are temporarily practicing the profession in Sweden.

What the medical record should contain

Chapter 3, Section 8 of the Swedish Board of Agriculture’s Regulations on Animal Health Personnel (SJVFS 2023:19) specifies the basic information that the medical record must contain whenever possible. This includes the animal owner’s name, address, and phone number; the species of the animal; the animal’s sex and age; and the animal’s identification or another description that makes it possible to identify the animal. According to Chapter 3, Section 9, the notes for each consultation should, if possible, include the date, a medical history with the reason for the visit, the animal’s clinical status, and a description of the examinations and treatments performed and by whom, along with a plan for further action when relevant. The record shall also, if possible, include the diagnosis and any differential diagnoses, what has been communicated to the animal owner regarding treatment options and prognosis, the advice provided—including discharge instructions—and the name and title of the person responsible for the examination. In the case of drug therapy, the medical record must, in accordance with Chapter 3, Section 10, also specify the drug’s name, strength, and dosage, along with the duration of treatment and the method of administration.

How long the medical record should be retained

According to Chapter 3, Sections 1 and 7 of the Swedish Board of Agriculture’s regulations (SJVFS 2023:19), medical records and supporting documents such as X-rays, referral forms, and laboratory results must be retained for at least five years. The period is calculated from the date of the last entry in the medical record.

Common Gaps in Medical Records

Most errors in a medical record involve information that the veterinarian knows but has not written down. The medical history becomes brief when the visit runs long, and follow-up instructions are given verbally to the pet owner but do not make it into the record. More examples and ways to avoid them can be found in the article on the most common mistakes in medical record-keeping.

A consistent structure makes the journal complete

A consistent structure makes it easier to see if anything is missing. Many clinics use SOAP, in which the notes are divided into subjective data, objective findings, assessment, and plan. How this structure can be used in veterinary medical records is described on the page about SOAP records for veterinarians. It is important that the entire clinic uses the same template, so that the records look the same regardless of who wrote them.

How Vetz Supports Medical Record Keeping

Vetz listens during the conversation with the pet owner and creates a structured draft of the medical record based on the clinic’s own templates. Within seconds of the conversation, you’ll have a draft using correct medical terminology that’s ready to review. Vetz can also highlight sections missing from the notes—such as the patient history or diagnosis—and remind you of follow-up appointments or check-ins.

Based on the note, Vetz suggests relevant diagnosis codes, as described in more detail on the page about AI-generated diagnosis code suggestions. With active integration, the completed medical record is transferred to the medical record system, and Vetz integrates with Provet Cloud, Vettigo, and MHK FileMaker. For more information on how the medical record system and Vetz are connected, see the article on medical record systems for veterinarians and the page on AI-powered medical record keeping.

You review and sign

A draft medical record from Vetz serves as a guide, and it is you, as the veterinarian, who reviews, edits, and signs the record. You can edit the note manually or ask Vetz to improve, rephrase, or clarify the text before you sign it. Vetz also recommends that you inform the pet owner that AI is used to assist in creating the note.

Learn more about Vetz

Would you like to see how Vetz creates draft medical records using your clinic’s templates? Schedule a demo or try Vetz for free for 14 days without providing your credit card information.