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1、VETERINARY BOARD OF THE NORTHERN TERRITORYGUIDELINES ON RECORD KEEPINGLEGISLATIVE CONTEXTVeterinarians ActThe Board is empowered under section 6(e) of the Veterinarians Actio issue guidelines on standards in relation to the provision of veterinary services that must be observed by registered veterin
2、arians and veterinary specialists.Failure to uphold or maintain contemporary professional standards constitutes incompetence within the meaning of misconduct as defined in section 28 of the Veterinarians Act.Code of Conduct - Regulation 9 - VeterinariansRegulationsThe Code of Conduct prescribed at R
3、egulation 9 of the Veterinarians Regulations requires registered veterinarians to be familiar with and abide by all legislation pertaining to veterinary practice; to maintain current standards of practice in their chosen areas of veterinary practice; and to carry out all veterinary services in accor
4、dance with the Boards guidelines.Specifically,Clause 1 一 BASIC PRINCIPLES OF PROFESSIONAL CONDUCTincludes the requirement under 1(1 )(b) for registered veterinarians to be familiar with and abide by all relevant legislation affecting their professional activity and behaviour (which includes the Vete
5、rinarians Act, Veterinarians Regulations, the Code of Conduct, and the Boards Guidelines).Clause 4 - KNOWLEDGE OF CURRENT STANDARD OF PRACTICEprovides at 4(1) that a registered veterinarian must maintain current standards of veterinary practice in their areas of veterinary practice and requires at 4
6、(1 )(b) that registered veterinarians always carry out veterinary services in accordance with those current standards and in accordance with the Boards guidelines/Clauses 11,12 and 16 of the Code of Conduct prescribe the following requirements on the provision, return and the maintenance of veterina
7、ry records:Clause 11 PROVISION OF RECORDS“A registered veterinarian who has previously treated an animal must, when requested to do so, and with the consent of the person responsible for the care of the animal, provide copies or originals of the case history records directly to another registered ve
8、terinarian who has taken over the treatment of the animal.HClause 12 RETURN OF RECORDS*A registered veterinarian to whom another registered veterinarian has referred an animal for treatment or a second opinion must return the records provided by the referring registered veterinarians as soon as prac
9、ticable.Clause 16 RECORDSA registered veterinarian must ensure that a detailed record of any consultation, procedure or treatment is made as soon as practicable.(1) The Board has the power to audit records.(2) The record must:(a) Be legible and in sufficient detail to enable another registered veter
10、inarian to continue the treatment of the animal; and(b) Include the results of any diagnostic tests, analysis and treatments.(3) A registered veterinarian must ensure that all records of any consultation, procedure or treatment are retained for at least 3 years after the records are made.GUILDELINES
11、 UNDER SECTION 6(e) OF THE VETERINARIANS ACTRECORD KEEPINGContemporary professional standards for veterinary practice require that case notes should provide sufficient details to enable another veterinarian to continue the treatment of the animal at any time.This includes (but is not necessarily lim
12、ited to) full details of:- any condition or injury- any examination, procedure, treatment- any provisional or definitive diagnosis-the results of any diagnostic testsestimates on likely extent and cost of treatment, given prior to treatment (as required by clause 7 of the Code of Conduct)- any drugs
13、 prescribed and directions provided-instructions given when the animal is discharged- any drugs administered (including amount and route)-anaesthetics given.(2)Records on AnaesthesiaThe Board does expect anaesthetics to be monitored eg heart rate, respiration rate, gum colour, palpable reflex etc. I
14、t is accepted that in some emergency situations this is not always possible. However, for routine procedures requiring anaesthetics an assistant is required. The Board does expect the drug, time and route given, to be recorded.(See separate Guidelines on Anaesthesia).In addition, veterinariansare re
15、quired under section 48 of the Medicines, Poisons and Therapeutic Goods Actto maintain a register recording details of the supply or administration of controlled drugs.Board Reliance on Accuracy of Case NotesWhen a question of conflicting information arises, the Board will rely on the accuracy of th
16、e case notes. If there is no written record of the action a veterinarian says was undertaken, the Board will assume that it has not been done.The case notes are an excellent opportunity for veterinarians to express their logicand efforts to do their best for a pet and its owner. Without them, the Board has to determine the likely chain of events, relying on the memory of both parties. Thereis no logical reason to solely be
