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RULES AND REGULATIONS

STATE BOARD OF VETERINARY MEDICINE

[49 PA. CODE CH. 31]

Recordkeeping

[37 Pa.B. 3240]
[Saturday, July 14, 2007]

   The State Board of Veterinary Medicine (Board) amends § 31.22 (relating to recordkeeping), to read as set forth in Annex A.

A.  Effective Date

   The final-form rulemaking will be effective upon publication in the Pennsylvania Bulletin.

B.  Statutory Authority

   Section 27.1 of the Veterinary Medicine Practice Act (act) (63 P. S. § 485.27a) requires the Board to promulgate regulations setting forth recordkeeping standards.

C.  Background and Purpose

   The Board determined that there is a need for greater specificity in its regulations regarding veterinary medical recordkeeping. This proposed rulemaking is intended to provide more specific requirements regarding the contents of veterinary medical records; to further define acceptable standards of veterinary medical recordkeeping; and to provide notice requirements for veterinarians who are retiring or closing their veterinary practices.

D.  Summary of Comments to Proposed Rulemaking and the Board's Response

   The proposed rulemaking was published at 36 Pa.B. 5984 (September 30, 2006), which provided for 30 days of public comment. No public comments were received. The Board received comments from the House Professional Licensure Committee (HPLC) and the Independent Regulatory Review Commission (IRRC) as part of their review under the Regulatory Review Act (71 P. S. §§ 745.1--745.15). The following is a summary of those comments and the Board's response.

   The HPLC asked whether the Board's rulemaking should include citations to Federal regulations regarding the recordkeeping responsibilities of veterinarians who provide services for production animals. Because Federal regulation of production animals and the veterinary care provided to these animals is so extensive, the Board has added a general statement to the final-form rulemaking that references 9 CFR (relating to animals and animal products). Subparts on birds, ruminants and swine are included in 9 CFR. In addition, 9 CFR includes testing and recordkeeping requirements regarding particular diseases, such as tuberculosis and scrapie.

   The HPLC asked, with respect to the final sentence of § 31.22(1), which requires notation on a veterinary medical record of the treating individual after each chart entry, whether the term ''individual'' could be both a veterinarian and a veterinary technician and if so, if the Board would consider using the term ''licensee'' instead of ''individual.'' Depending on the treatment, a veterinary medical treatment may be performed by a veterinarian, a certified veterinary technician or an unlicensed veterinary assistant. Because the term ''licensee'' is underinclusive, the Board determined that the term ''individual'' should be retained.

   The HPLC made several comments regarding drafting which were corrected by the editors of the Pennsylvania Bulletin. The Board agrees with the subtitles added by the editors to § 31.22(4) and (5). The Board also agrees with the editors regarding the use of numbered paragraphs rather than alphabetized subsections.

   The HPLC noted that the Board used the term ''patient'' and ''animal'' in various parts of the rulemaking and inquired whether one term should be used consistently. The Board amended the final-form rulemaking to use the term ''patient'' throughout.

   Finally, the HPLC questioned § 31.32(10), noting that the first sentence established a bright line rule that notice must be given to clients at least 30 days in advance of a planned retirement or closing of a veterinary facility but that the last sentence stated that if prior notice was not possible, the successor veterinarian was required to provide notice. The HPLC asked the Board to provide guidance regarding: (1) when the 30-day notice is not required; and (2) under what circumstances the successor veterinarian will have to provide notice.

   The 30-day notice is always required for planned events, such as retirement or the closing of a veterinary practice. However, the 30-day notice would not be required when it is not possible, such as in the case of an unplanned closure due to acute illness or death of a veterinarian. A veterinarian who does not provide at least 30 days advance notice when advance notice was possible would be subject to discipline under section 21(1) of the act (63 P. S. § 485.21(1)) for willful violation of a Board regulation. The successor veterinarian is required to provide notice whenever prior notice was not provided.

   IRRC submitted comments to the Board on November 29, 2006. IRRC noted three concerns. First, IRRC also commented that the Board appeared to use the terms ''patient'' and ''animal'' interchangeably throughout the rulemaking and recommended that one term be used consistently. This concern has been addressed.

   Second, IRRC asked for further clarification of a ''problem-oriented medical record'' and specifically inquired what methods are acceptable to the Board. A problem-oriented medical record is acceptable to the Board. Recordkeeping systems with different nomenclature that include record of subjective and objective assessment, treatment plan and documentation of treatment provided will be acceptable to the Board.

   Finally, IRRC agreed with the HPLC comments regarding citation to Federal regulations regarding veterinary medical recordkeeping for production animals and recommended a cross reference be added to the Board's rulemaking. The Board has added the requested information.

E.  Fiscal Impact

   The Board believes that the final-form rulemaking should have little or no fiscal impact on licensees as the regulation represents what is already the acceptable and prevailing standard of practice with regard to veterinary medical recordkeeping. Veterinarians who are not practicing in accordance with recognized standards may experience some costs in conforming their recordkeeping to the requirements in the regulation. The Board may experience some costs in prosecuting veterinarians whose recordkeeping does not conform to the regulation. There are no costs to other political subdivisions as the Board is self-supporting.

F.  Paperwork Requirements

   Veterinarians who are not practicing in accordance with recognized standards may experience additional paperwork requirements to practice in accordance with the regulation. Neither the Board nor political subdivisions will experience additional paperwork requirements as a result of the final-form rulemaking.

G.  Sunset Date

   The Board continuously monitors its regulations. Therefore, no sunset date has been assigned.

H.  Regulatory Review

   Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on September 20, 2006, the Board submitted a copy of the notice of proposed rulemaking, published at 36 Pa.B. 5984, to IRRC and the Chairpersons of the HPLC and the Senate Consumer Protection and Professional Licensure Committee (SCP/PLC) for review and comment.

   Under section 5(c) of the Regulatory Review Act, IRRC, the HPLC and the SCP/PLC were provided with copies of the comments received during the public comment period, as well as other documents when requested. In preparing the final-form rulemaking, the Department has considered all comments from IRRC, the HPLC, the SCP/PLC and the public.

   Under section 5.1(j.2) of the Regulatory Review Act (71 P. S. § 745.5a(j.2)), on May 23, 2007, the final-form rulemaking was approved by the HPLC. On June 6, 2007, the final-form rulemaking was deemed approved by the SCP/PLC. Under section 5.1(e) of the Regulatory Review Act, IRRC met on June 7, 2007, and approved the final-form rulemaking.

I.  Additional Information

   Further information may be obtained by contacting J. Robert Kline, Administrative Assistant, State Board of Veterinary Medicine, P. O. Box 2649, Harrisburg, PA 17105-2649, or from the Department website, www.dos. state.pa.us.

J.  Findings

The Board finds that:

   (1)  Public notice of proposed rulemaking was given under sections 201 and 202 of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. §§ 1201 and 1202), and the regulations promulgated thereunder, 1 Pa. Code §§ 7.1 and 7.2.

   (2)  A public comment period was provided as required by law and all comments were considered.

   (3)  This final-form rulemaking is necessary and appropriate for administering and enforcing the authorizing act identified in this Preamble.

K.  Order

   The Board, acting under its authorizing statute, orders that:

   (a)  The regulations of the Board, 49 Pa. Code Chapter 31, are amended by amending § 31.22 to read as set forth in Annex A.

   (b)  The Board shall submit this order and Annex A to the Office of General Counsel and the Office of Attorney General as required by law.

   (c)  The Board shall certify this order and Annex A and deposit them with the Legislative Reference Bureau as required by law.

   (d)  This order shall take effect upon publication in the Pennsylvania Bulletin.

THOMAS J. MCGRATH, D.V.M.,   
Chairperson

(Editor's Note: For the text of the order of the Independent Regulatory Review Commission, relating to this document, see 37 Pa.B. 2909 (June 23, 2007).)

Fiscal Note:  Fiscal Note 16A-5719 remains valid for the final adoption of the subject regulation.

Annex A

TITLE 49.  PROFESSIONAL AND VOCATIONAL STANDARDS

PART I.  DEPARTMENT OF STATE

Subpart A.  PROFESSIONAL AND OCCUPATIONAL AFFAIRS

CHAPTER 31.  STATE BOARD OF VETERINARY MEDICINE

PROFESSIONAL CONDUCT

§ 31.22.  Recordkeeping.

   Veterinary medical records serve as a basis for planning patient care and as a means of communicating among members of the veterinary practice. The records furnish documentary evidence of the patient's illness, hospital care and treatment and serve as a basis for review, study and evaluation of the care and treatment rendered by the veterinarian. A veterinary medical record shall be kept in a problem-oriented or similar format that allows any veterinarian, by reading the record, to proceed with the care and treatment of the patient and allow the Board or other agency to determine the advice and treatment recommended and performed. This section does not apply to laboratory animal practice.

   (1)  Record required. A veterinarian shall maintain a separate veterinary medical record for each patient, herd or group, as appropriate, which accurately, legibly and completely reflects the evaluation and treatment of the patient or patients. The veterinary medical record must identify the treating individual after each chart entry.

   (2)  Identity of patient. The veterinary medical record must include, at a minimum, the following information to identify the patient, herd or group:

   (i)  Client identification.

   (ii)  Appropriate patient identification, which may include species, breed, age, sex, weight, name or identity number or numbers, color and identifying markings, and whether neutered, spayed or intact.

   (3)  Minimum content of record. Production animal veterinarians shall comply with all Federal recordkeeping requirements, including requirements in 9 CFR (relating to animals and animal products). Veterinary medical records for other animals must include:

   (i)  Vaccination history.

   (ii)  Previous medical history, presenting symptoms and complaint.

   (iii)  Date of each examination.

   (iv)  Diagnosis.

   (v)  Results and findings of pathological or clinical laboratory examination.

   (vi)  Findings of radiological examination.

   (vii)  Medical or surgical treatment.

   (viii)  Other diagnostic, corrective or therapeutic procedures.

   (ix)  Documentation of drugs administered, prescribed or dispensed, including dosage.

   (x)  Documentation of surgical and dental procedures, including type and dosage of anesthesia, and dental charting.

   (4)  Communication with client. The veterinary medical record of any patient, except a production animal, must document communication with the client, including the client's consent to or rejection of recommended diagnostic tests, treatments and drugs.

   (5)  Retention of records. Records shall be maintained for a minimum of 3 years from the date that the patient was last treated by the veterinarian.

   (6)   Ownership and use of records. The records of a veterinary practice are the sole property of that facility, and when a veterinarian leaves salaried employment therein, the departing veterinarian may not copy, remove or make subsequent use of the records, without the consent of the owner of the veterinary practice.

   (7)  Radiographs. A radiograph is the property of the veterinary practice that originally ordered it to be prepared. Radiographs shall be properly identified by hospital name, date, name of client, name of patient and positional marker. A radiograph shall be released upon the written request of another veterinarian who has the written authorization of the client. The radiograph shall be returned to the veterinary practice that originally ordered it to be prepared within a reasonable time.

   (8)   Release of information to clients. A veterinarian shall release a summary or a copy of the veterinary medical records of a patient to the client within 3 business days of receipt of the client's written request. A veterinarian may charge a reasonable fee for duplicating veterinary medical records and for preparation of veterinary medical record file summaries for release to clients. A veterinarian may not withhold the release of veterinary medical records or summaries to clients for nonpayment of a professional fee. The release of veterinary medical records or summaries to clients under these circumstances does not constitute a waiver by the veterinarian of the fee claimed.

   (9)   Veterinary medical records for vaccination clinics. A veterinarian providing veterinary medical services to the public for a public health vaccination clinic or an animal health vaccination clinic shall prepare a veterinary medical record that includes, at a minimum, an identification of the client and patient, the vaccine lot number, and the date and dosage administered. A veterinarian who provides veterinary medical services to a vaccination clinic shall provide a means for clients to obtain advice pertaining to postvaccine reactions for the 24-hour period immediately following the time of vaccination.

   (10)  Veterinary records of retiring veterinarian or a veterinary practice that is closing. A veterinarian shall notify clients, in writing, at least 30 days prior to the date of a planned retirement or closing of a veterinary practice. The written notice must include instructions on how to obtain copies of veterinary medical records from the veterinarian or other custodian of the records and the name, address and telephone number of the person purchasing the practice, if applicable. Veterinary medical records must remain available to clients for 3 years after the date the veterinarian retires or the practice is closed. If prior notice could not be provided, a successor veterinarian shall notify clients within 60 days of the date the successor takes over the practice.

[Pa.B. Doc. No. 07-1233. Filed for public inspection July 13, 2007, 9:00 a.m.]



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