Veterinary and Para-Veterinary Professions Act, 1982 (Act No. 19 of 1982)RulesRules relating to the Practising of Para-Veterinary Profession of Veterinary Nurse13. Records at veterinary nursing facility |
| (1) | The veterinary nurse must maintain records, for each animal or group of animals which are legible, accurate and permit prompt retrieval, if and when necessary. |
| (2) | Records must contain the following information for individual animals as applicable— |
| (a) | The date or period of the examination or consultation; |
| (b) | Name of the veterinarian who treated the patient and the referral letter; |
| (c) | Client’s identification; |
| (d) | Patient name, other forms of identification, as well as the species, breed, gender and age; |
| (e) | Clinical information for the purposes of continuous care and assessment; |
| (f) | Vaccination record; |
| (g) | Special procedures; |
| (h) | Problem attended to and/or diagnosis made by the attending veterinarian; |
| (i) | Treatment and scripts issued by the veterinarian; and |
| (j) | Discharge instructions. |
| (3) | All records referred to in Rule 14(2) must be retained by the principal of the veterinary nursing facility for a period of five years from the patient’s last visit. |
| (4) | Records referred to in Rule 14(4) relating to a complaint, charge or allegation lodged with Council in terms of section 31(1) of the Act must be presented to Council within seventy-two (72) hours of being requested to submit such records, or as otherwise arranged with Council. |
| (5) | Proper security arrangements must be made to protect records from loss, fire, alterations, additions, supplements or unauthorised use; electronic records must be backed up on a daily basis and electronic backups should be stored off-site. |
| (6) | Any alterations, additions and/or supplements to any records must be entered as a supplement to said record and must be dated and clearly defined as such. |
(7)
| (a) | The principal of a veterinary nursing facility will be responsible for confirming the identity of the attending veterinary para-professional to Council, where a complaint is lodged against his/her veterinary nursing facility. |
| (b) | The principal of a veterinary nursing facility will be responsible for providing the records referred to in Rule 6(5), should a complaint be lodged against the professional no longer in the employ of the principal of the facility, subsequent to the date on which the complaint originated. |
| (c) | If the principal of a facility fails to comply with the provisions of Rule 15(7)(a) he/she will be held accountable for any unprofessional conduct arising from such a complaint. |