MONTH 2022 Jurisdiction Update

PART 24. TEXAS BOARD OF VETERINARY MEDICAL EXAMINERS 

CHAPTER 573. RULES OF PROFESSIONAL CONDUCT 
SUBCHAPTER F. RECORDS KEEPING 

22 TAC §573.52 

The Texas Board of Veterinary Medical Examiners adopts amendments to §573.52, concerning Veterinarian Patient Record Keeping. These amendments are adopted with changes to the proposed text as published in the June 10, 2022, issue of the Texas Register (47 TexReg 3396). The rule will be republished.  

The amendments are adopted, in part, to clarify what information is required for compliance. The amendments also update the rule in keeping with advances in the medical information modalities offered to the animal-owning public and to increase the standards of veterinary medical practice. The changes reflect non-substantive variations from the proposed amendment. The changes affect no new persons, entities, or subjects other than those given notice, and the rule, as adopted, does not impose more stringent requirements that the proposed version.  

The following entities furnished written comments on the proposed amendment: Texas Veterinary Medical Association (hereinafter “TVMA”) and several other individual veterinarians.  

TVMA and other individual veterinarians’ comments essentially covered the same concerns contending the proposed rule, under subsection (a)(6) Examination Findings, requires the veterinarian to record medical data such as pulse and respiration rate, when the information often times is not useful and it would subject the veterinarian to disciplinary action for failing to record unnecessary information. The Board disagrees because under subsection (a)(6) the rule says, “if required for diagnosis or treatment and is not difficult to obtain,” they would be required to record the listed medical information. The conditional language in the said subsection clearly allows the veterinarian latitude to practice medicine the way they see fit.  

Therefore, a veterinarian is not required to record the information they determine is not required for diagnosis or treatment or where it is difficult to obtain. 

TVMA and other veterinarians commented against subsection (a)(12), regarding anesthesia monitoring. They contended it is too difficult to free up their aseptic hands to record real-time data or to recall every time they checked significant data. The Board disagrees that requiring basic information under subsections (a)(11) and (a) (12), such as the description of the procedure, the name of the surgeon, type of sedative and anesthetic agent used, route of administration, and dosage, is too much to ask of a medical professional. The requirement is very broad and a basic surgical report. For example, a horse castration would be sufficiently reported by documenting the horse’s name, the owner’s name, the doctor’s name, name of sedative–Ketamine, Xylazine, and Valium–time of surgery, routine castration performed on right lateral recumbency, removed two testicles using an emasculator, and that the horse stood without complications at a time certain. This section in the rule gives large latitude to the practitioner to decide what they want to record. 

The amendments are adopted under the authority of §§801.151(b) and 801.151(c) of the Texas Veterinary Licensing Act (Chapter 801, Texas Occupations Code). The Board interprets §801.151(c) as authorizing the agency to protect the public through adopting rules of professional conduct appropriate to establish and maintain a high standard of integrity, skills, and practice in the veterinary medicine profession. 

• 573.52.Veterinarian Patient Record Keeping.

(a) A veterinarian performing a physical examination, diagnosis, treatment, or surgery on an animal or
      group of animals shall prepare a legibly written record or computer record concerning the animals
      containing, at a minimum, the following information: 
              (1) name, address, and telephone number of the owner; 
              (2) identity of the species, animal, herd, or flock; 
              (3) except for herds or flocks, the age, sex, color, and breed; 
              (4) dates of examination, treatment and surgery; 
              (5) brief history of the condition of each animal, litter, herd, or flock; 

(6) examination findings, if required for diagnosis or treatment and is not difficult to obtain: 
              (A) weight – actual or estimated; 
              (B) temperature; 
              (C) pulse;  
              (D) respiration; and 
              (E) any additional findings needed for diagnosis; 

(7) laboratory and radiographic tests performed and reports; 

(8) differential diagnosis; referrals/consultations; to/with specialists and the client’s response; 

(9) procedures performed/treatment given and results; 

(10) drugs (and their dosages) administered, dispensed, or prescribed; 

(11) surgical procedures shall include a description of the procedure, the name of the surgeon, the type of sedative/anesthetic agent used, the route of administration and the dosage; and 

(12) anesthesia monitoring performed during surgical procedures.
              (b) Individual records must be maintained on each patient, except that records on livestock
                   or litters of animals may be maintained on a per-client basis. Records pertaining to these
                   animals may be kept in a daily log or billing records, provided that the treatment
                   information is substantial enough to identify these animals and the medical care provided. 
              (c) Medical records and radiographs are the physical property of the hospital or the proprietor
                   of the practice that prepared them. Records, including radiographs, must be maintained
                   for a minimum of three years after the last visit.              
              (d) Medical records shall be released upon request from a treating veterinarian with a
                    legitimate interest, and shall be returned to the originating practice within a reasonable
                    time if requested. Copies of records must be made available upon request from the owner
                    of an animal at a reasonable cost to the owner and within a reasonable time. A veterinarian
                    may not withhold the release of veterinary medical records for nonpayment of a professional
                    fee. 
              (e) All regulated substances shall be recorded as required by federal and/or state regulations. 
              (f) Any signed acknowledgment required by §§573.14 and 573.16 – 573.18 (relating to all
                   complementary therapies).  

The agency certifies that legal counsel has reviewed the adoption and found it to be a valid exercise of the agency’s legal authority. 

Filed with the Office of the Secretary of State on July 27, 2022. 

New Rule Seeks To Clarify Information Required in Veterinarians’ Records 

The Texas Board of Veterinary Medical Examiners (TBVME) has adopted a completely revised version of its patient recordkeeping rule, Texas Administrative Code Section 573.52. The new rule, which went into effect on August 16, is modeled after the rule used by the Ohio Board of Veterinary Medical Examiners for practitioners in that state. Board members have stated over the past few months that the previous Texas rule had become too cumbersome and difficult for veterinarians to understand, making them susceptible to unintended violations of recordkeeping requirements. TBVME attempted to address the problem by proposing changes in January. 

However, following substantial negative feedback from TVMA and veterinarians, TBVME decided that, rather than amending its old rule, adopting a simplified model from another state would be a better approach. The newly adopted rule is the result of that process. 

Like the old rule, the new version lists certain examination findings and patient information that must be included in veterinarians’ records, most of which practitioners likely already include in their regular course of business. However, there are some differences between the old rule and the new one, and veterinarians should be aware: 

• If it is required for diagnosis or treatment and is not difficult to obtain, records now must include the patient’s weight (actual or estimated), temperature, pulse, respiration, and any additional findings needed for diagnosis. As we did when this rule was first proposed in January, TVMA objected to inclusion of pulse and respiration rates because practitioners have noted that, typically, they are not useful in making a diagnosis. In adopting this requirement anyway, TBVME stated that the conditional language in bold above clearly allows a veterinarian the latitude to practice medicine as they see fit. The Board goes on to state that the new rule does not require a veterinarian to record information they determine is not required for diagnosis or treatment or where it is difficult to obtain. The bottom line for practitioners is that they should always note any factor that is relevant to their decisions relating to diagnosis and treatment of a particular patient. 
• The new rule requires records to include “anesthesia monitoring performed during surgical procedures.” TVMA objected to this requirement on the grounds that it is often difficult for surgeons operating solo to free up their aseptic hands to record real-time monitoring data or to recall each time they checked significant data during a procedure. In its statement adopting the new rule over these objections, the Board stated that it gives practitioners large latitude to decide what they want to record. As an example, they stated that a record of a horse castration would be sufficient if it includes the following: the horse’s name, the owner’s name, the doctor’s name, the name of the sedative used, time of surgery, a medical statement of procedure(s) performed and notation of the time at which the horse stood without complication. Additionally, as veterinarians with good recordkeeping practices likely are already doing, any abnormal events occurring during surgery should be noted, as well as the steps taken to address those events.  
• Under the new rule, a veterinarian may share their patient’s records with another treating veterinarian upon request, without the need for approval from the client. In most cases, clients are happy to let a veterinarian share their records with another doctor who will be treating their pet. However, practitioners have noted some instances in which owners of aggressive pets do not wish to share the animal’s history with a new veterinarian when they switch providers. Confidentiality rules previously prohibited veterinarians from providing this information to a new veterinarian without the owner’s consent, putting the receiving veterinarian’s staff, patients and clients at risk. The new rule resolves that issue, and TVMA supported this change during the rulemaking process. 
• In adopting the Ohio rule, the Board reduced the time that veterinarians must maintain patient records from five years from the date of the last visit to three years from that date.  
• In streamlining the rule, the Board removed provisions requiring veterinarians to maintain records that are subject to pending administrative, civil or criminal proceedings for the duration of those proceedings, even if it is beyond the normal retention period. However, TVMA advises members that it is still a best practice to maintain records for the duration of these cases if the veterinarian is aware of such proceedings. 

To view the new rule in its entirety, along with the Board’s commentary, click here.