Record-keeping Requirements for Veterinarians: What the Swedish Board of Agriculture Requires of Medical Records
The medical record is the veterinarian’s most important document, and the rules for keeping it are clearer than many people think. This summary is based on the Swedish Board of Agriculture’s webpage on the obligations of animal health professionals and outlines who is responsible for maintaining the medical record, when it should be written, what it should contain, and how long it should be retained.
Who Is Responsible for Keeping Records
According to the Swedish Board of Agriculture, this group includes animal health professionals who are licensed veterinarians or veterinary technicians, certified farriers, or certified and licensed physical therapists, occupational therapists, dentists, or nurses. Members of this group must always maintain medical records in connection with patient visits or consultations.
The Swedish Board of Agriculture also specifies an exception. If the consultation concerns general matters, no record needs to be made.
When to Write the Medical Record
The Swedish Board of Agriculture states that medical records must be written immediately following the visit or consultation. For many clinics, this is the most difficult requirement to meet, since medical records often pile up and are written at the end of the day.
A clinic that wants to comply with this requirement therefore needs a procedure in which the medical record is completed while the visit is still fresh in the clinician’s mind. This may involve setting aside time between visits or providing support that allows the medical record to be completed during the visit itself.
What the medical record should contain
The Swedish Board of Agriculture lists the information about the animal owner and the animal that must be included in the record:
- The animal owner's name, address, and phone number, as well as the facility number, if applicable.
- Animal species.
- The animal's sex.
- The animal's age or age group.
- The animal's identity.
According to the Swedish Board of Agriculture, for each consultation or treatment, the medical record must also include the following:
- Date and time.
- Medical history and reason for the consultation.
- Clinical status.
- Diagnosis and possible differential diagnoses.
- Prognosis and plan for further actions, including discharge instructions.
The requirement for discharge instructions in the plan means that the instructions provided to the pet owner are part of the medical record. The article on discharge instructions describes how these instructions can be generated directly from the medical record.
Information Regarding Medication Treatment
According to the Swedish Board of Agriculture, when an animal is treated with medication, the medical record must include the following additional information:
- Name of the drug.
- Strength and dosage.
- Duration of treatment.
- Method of administration.
- Withdrawal period, when the animal is used for food production.
Language, Saving, and Corrections
According to the Swedish Board of Agriculture, the logbook may be written in Swedish or English. However, important conclusions, final notes, and summaries must be written in Swedish.
Records must be retained for at least five years, counting from the date of the last entry. An error in a record must not be made illegible. Instead, a line must be drawn through the error, and the correction must be signed and dated.
The Swedish Board of Agriculture also states that there are no regulations regarding the format in which medical records must be kept. They may therefore be kept on paper or digitally, and the choice of medical record system is up to the clinic. The requirements for a medical record system are described in the guide to medical record systems for veterinarians.
How the clinic monitors its procedures
These requirements can be used as a checklist for the clinic’s own procedures. Ask yourself a few questions about a typical week:
- Are the medical records completed right after the appointments, or are they written up after closing time?
- Do the medical record templates cover all the information listed by the Swedish Board of Agriculture?
- Is the medication information included every time a medication is used?
- How are corrections displayed in the medical record system, and is it possible to see who made which changes?
- Are summaries and final notes written in Swedish even when the rest of the medical record is in English?
A medical record template that follows a fixed structure makes it easier to include all the necessary information. SOAP is one such structure, and how it relates to the requirements is described in the guide on SOAP medical records for veterinarians.
AI-Based Record-Keeping and the Requirements
The requirement to write the medical record immediately following the visit is one of the reasons clinics are beginning to use AI. Vetz listens to the conversation with the pet owner during the visit and writes a draft medical record based on the clinic’s own templates, so that the template can be customized to include the necessary information. Vetz can also flag missing information, such as the patient’s medical history or diagnosis.
The veterinarian always reviews and approves the medical record before it is transferred to the medical record system, and the veterinarian remains responsible for its content. For more information about the workflow, see the guide on AI-powered medical record keeping for veterinarians.
Learn more about Vetz
Would you like to see how Vetz can complete the medical record during the visit itself? Schedule a demo, and we’ll show you using your own medical record templates.