| (1) | The attending veterinary professional shall maintain records for each animal or group of animals which are legible, accurate and permit prompt retrieval of information. |
| (2) | Records shall, where applicable, contain the following information— |
| (a) | client’s identification; |
| (b) | patient name, other forms of identification, as well as the specie, breed, gender and age; |
| (h) | discharge instructions. |
| (3) | Veterinary professionals attending to racing horses, excluding horses on spelling farms or studs registered with the National Horse Racing Authority of Southern Africa shall— |
[Words preceding subrule (3)(a) substituted by section 11 of Notice 868 of 2009]
| (a) | complete a veterinary case sheet in duplicate containing the following information— |
| (i) | premise identification; |
| (ii) | patient identification; |
| (b) | Retain the original completed case sheet and hand a copy of the case sheet to the person requesting the treatment. |
| (4) | All records including diagnostic images, laboratory and pathology results shall be retained by the principal of the veterinary facility for a period of three years from the patient's last visit. |
| (5) | Records referred to in Rule 26(4) relating to a complaint, charge or allegation lodged with Council in terms of section 31(1) of the Act shall be presented to Council on request. |
| (6) | Proper security arrangements shall be made to protect medical records from loss, fire, alterations or unauthorised use. |
| (7) | Diagnostic images shall, on request of the owner of a patient or his/her representative, be handed over to such owner or representative, who shall sign a release in exchange for receipt of such records. Provided that a register be kept of the transfer indicating the date thereof as well as the particulars of the owner concerned. |
(8)
| (a) | The principal of a veterinary facility will be responsible for confirming the identity of the attending veterinary professional to Council, where a complaint is lodged against his/her veterinary facility. |
| (b) | Should the principal of a facility fail to comply with the provisions of Rule 8(a), he/herself will than be held accountable for any unprofessional conduct arising from such a complaint. |
[Subrule (8) inserted by section 12 of Notice 868 of 2009]
[Notice 868 of 2009 makes reference in section 12 to the deletion of subrule (12) which does not appear to exist]
