This document summarizes a veterinary lecture on using medical records as a defense against licensing board actions. It discusses veterinary medical board requirements for recordkeeping, including documenting physical exams and anesthesia procedures. Licensing boards can obtain records through subpoenas or patient releases to investigate complaints. Poor or incomplete records can lead to citations or accusations for improper recordkeeping even if care was appropriate. Medical records are crucial, as board experts will use them to evaluate the standard of care. Defensive recordkeeping is important to protect veterinarians.

1. LOOMIS BASIN VETERINARY CLINIC
WINTER LECTURE SERIES
Medical Records as a Defense to
your Veterinary License

2.  Experience
• Simas & Associates, Ltd. –2002 to present
• Deputy Attorney General, Office of the Attorney General
• American Veterinary Medical Legal Association
• California Academy of Attorneys for Health Care
Professionals
• Legal Counsel, California Physical Therapy Association
 Practice Areas
• Veterinary Medical Board and Malpractice Defense
• Health Care Law
• Professional Licensing and Regulation
• Civil Litigation and Appeals
• Employment Law and Workplace Regulation

3.  Veterinary Medical Board’s Standards for
Recordkeeping
• Test Your Knowledge
• What the Board Requires in your Records
 Veterinary Medical Records Compared
to Medical Records
 How Licensing Boards Build Cases Using
Medical Records
 Accusations and Citations for Improper
Recordkeeping

5.  Test your knowledge

6. QUESTION:
When conducting a physical
examination of a patient, it is
proper to record just “normal” if
the readings/data are normal?

7.  False-probably not.
• Veterinary Medical Board
Regulations (to be discussed)
provide that you must record “data,
including that obtained by
instrumentation, from the physical
examination.”
 Is just writing “normal” recording
“data”?

8.  HYPOTHETICAL:
Jojo, a 5 year old beagle, presents on referral
from the regular veterinarian to a multi-
speciality emergency clinic for a post
surgical pyometra consult with an internal
medicine specialist Dr. McGillicuddy at 4:48
p.m. Dr. McGillicuddy conducts a physical
exam upon presentation and refers the
matter at 5:24 p.m.
to the surgeon Dr. Barnabus whose surgical
practice and office are at the same clinic.

9.  Dr. Barnabus reviews the record with
Dr. McGillicuddy, including the
results of her physical exam. Dr.
Barnabus performs surgery at 5:48
p.m. and saves the dog’s life.
 Does Dr. Barnabus have to perform a
separate physical exam?

10.  Veterinary Board said YES and sent Dr.
Barnabus an “Education Letter” which
stated:
• The Veterinary Medical Board has completed its
internal investigation of the above referenced
complaint, and is closing this case with this letter
of education. Although the Board did not take any
action against your license at this time you are
advised that any violation of the practice act,
including regulations of the Board, can result in
the Board pursuing enforcement action including,
but not limited to, the issuance of a citation and
fine.

11.  In an effort to educate licensees and to
maintain the minimum standards of practice
in California, the Board is taking this
opportunity to remind you that as a licensee
you are obligated to be in compliance with
the laws and regulations governing
veterinary medicine in CA at all times. The
Board is advising you to take time to
familiarize yourself with the information
required in all medical records and to take
steps to insure that in the future your
records contain all required information.

12.  The Board cited its
recordkeeping regulation 2032.3,
subdivision (7) which provides
that the record must contain:
 (7) Data, including that obtained by instrumentation,
from the physical examination (No physical exam
findings recorded for March 3, 2011); and
 That there has to be a physical examination 12 hours
prior to anesthesia (Regulation 2032.4).

13. QUESTION:
A veterinarian must keep records
for which following period
according to the Board?
a) 4 years from the last visit
b) 3 years from the first visit
c) 3 years from the last visit
d) 4 years from the last visit

14.  ANSWER:
 c) 3 years from the last visit
according to Title 16, California
Code of Regulations, section 2032.3
 Can be a defense in a Veterinary
Medical Board Investigation

15.  QUESTION:
 Mrs. Jones brings her cat Fluffy in for boarding. The
cat suffers from diabetes. Mrs. Jones is going on a
cruise for 10 days and will be unreachable.
 STOP: see where this is headed yet?
 Coast Hills Veterinary Clinic takes the cat in for
boarding. On day two of the Fluffy’s stay, she gets
really sick, vomiting, etc. and needs IV fluids.
 What should the attending veterinarian do?
 Can the doctor just treat Fluffy in the kennel?

16.  ISSUES:
 Was there a physical exam?
 Was there a
veterinarian/patient/client
relationship?
 Boarding v. Hospitalization—big
issue for the Board regarding
recordkeeping.

17.  What
the Board
Requires in Your
Records

18.  Veterinary Practice Act Provides (Bus. &
Prof. Code § 4855):
 A veterinarian subject to the provisions of this chapter shall,
as required by regulation of the board, keep a written record
of all animals receiving veterinary services, and provide a
summary of that record to the owner of animals receiving
veterinary services, when requested. The minimum amount
of information which shall be included in written records
and summaries shall be established by the board. The
minimum duration of time for which a licensed premise shall
retain the written record or a complete copy of the written
record shall be determined by the board.

19.  Veterinary Medical Board Regulations Title
16, California Code of Regulations, §2032.3
provides:
 (a) Every veterinarian performing any act requiring a license pursuant to
the provisions of Chapter 11, Division 2, of the code, upon any animal or
group of animals shall prepare a legible, written or computer generated
record concerning the animal or animals which shall contain the following
information:
• (1) Name or initials of the veterinarian responsible for
entries.
• (2) Name, address and phone number of the client.
• (3) Name or identity of the animal, herd or flock.

20.  (4) Except for herds or flocks, age, sex, breed, species, and
color of the animal.
 (5) Dates (beginning and ending) of custody of the animal, if
applicable.
 (6) A history or pertinent information as it pertains to each
animal, herd, or flock's medical status.
 (7) Data, including that obtained by instrumentation, from the
physical examination.
 (8) Treatment and intended treatment plan, including
medications, dosages and frequency of use.

21.  (9) Records for surgical procedures shall include a
description of the procedure, the name of the surgeon, the
type of sedative/anesthetic agents used, their route of
administration, and their strength if available in more than
one strength.
 (10) Diagnosis or tentative diagnosis at the beginning of
custody of animal.
 (11) If relevant, a prognosis of the animal's condition.
 (12) All medications and treatments prescribed and
dispensed, including strength, dosage, quantity, and
frequency.
 (13) Daily progress, if relevant, and disposition of the case.

22.  Recordkeeping for patients under
anesthesia (Title 16, Cal. Code Regs. Section
2032.4)
• For all surgeries under anesthesia, you must chart:
 Veterinarian Physical examination within 12 hours of the
administration of general anesthesia
 Method of respiratory monitoring which “may” include
 Observation of animal’s chest movements;
 Observing rebreathing bag; or
 Respirometer
 Method of cardiac monitoring “shall be provided” and
“may” include use of stethoscope or electrocardiographic
monitor
 Recommend charting observation time for safe recovery

24.  Medical Practice Act –Business &
Professions Code §2266 provides:
• The failure of a physician and surgeon to
maintain adequate and accurate records relating
to the provision of services to their patients
constitutes unprofessional conduct.
• What is “adequate and accurate”?
 Depends upon clinical circumstances
 Matter of expert opinion

25. A Comprehensive Patient Record
Contains:
Patient’scondition and treatment
Any consultation informing the patient of his or
her condition
Discussion of intended procedures, risks,
hazards, and alternative therapy
Any instructions given to a patient by telephone

26.  Any cautions regarding prescription drugs that
may interfere with a patient’s occupation or
driving safely
 Special note should be made of any allergies or
sensitivities
 Surgical records which are comprehensive and
promptly dictated or written. The anesthetist
should record both pre- and post-operative
information.

27.  Instructions to patients on follow-up care.
 Pathology and X-ray reports.
 The justification for treatment.
• Source: Guide to the Laws of Practicing Medicine
by Physicians and Surgeons, Sixth Edition, 2010,
Medical Board of California
(http://www.mbc.ca.gov/publications/laws_guide.pdf)

28. Contrast with Medical Board record
requirements:
• Veterinary Board does not rely exclusively upon
standard of care and judgment of practitioners
• Veterinary Board has very specific requirements
• Does not rely upon “expert testimony” to
determine violation
• More objective?
• More nitpicky?
• Which is better?

30. After a licensing board receives a formal
complaint or has other reason to
investigate, it has the following tools to
do so:
• Subpoenas
• Release from complaining party
• Interviews
• Medical records

31. Subpoenas:
 Under the Administrative Procedure Act (Govt. Code §
11180), the head of each department may issue a
subpoena to investigate:
 All matters relating to the business activities and
subjects of the department's jurisdiction;
 The violation of any law or any rule or order of the
department; and
 Any other matter that some rule of law authorizes the
department to investigate.

32.  Other methods of licensing Boards obtaining
records (how your charts get to the Board):
• Release from complaining party or patient
(often without licensee’s knowledge)
• Premises Inspections
• 30 Day Demand Letter for Records
 Failure to respond as “unprofessional conduct”
 “Consulting veterinarian” v. “respondent”
• Reports of Settlement
• Other clinic’s records

34.  Licensing Board actions against health care
professionals
• Accusations
• Citations
 Recordkeeping violations (grounds for license
discipline)
• Failure to keep “adequate” records
• Failure to keep records
• Failure to document treatment in the records
• Failure to document things required by Board (e.g.
anesthesia requires physical exam within 12 hours,
discharge summary for PT Board, etc.)

35.  How recordkeeping problems manifest in
a licensing hearing:
• The Golden Rule : “If it is not in the record, it
did not happen”
 Difficult patient case
 Difficult client
 Owner-declined service
 Referrals
 History & Physical
 Prescribing issues
 Pain management

36. • If the licensee met the standard of care, it
must be in the record
 “Defensive recordkeeping”
 Can be the difference between a finding of
negligence or not
 Can cause the Board to bring a case or not
 Alterations to record or amendments
 Can be viewed as “altering records”
 Scary examples:
 Relief veterinarian took set of records “home to complete”
 Veterinarian had separate “intake sheet” as part of record
 Amendments to computerized records

37.  Medical records and use of experts in
licensing defense cases
• Medical records are the tool of the expert
witnesses
• Board experts look first at medical records
• Medical records can cause license discipline
or other issues even if care was proper

38.  Examples
 Veterinary Board overnight hospitalization case
 Overnight monitoring not in record
 Veterinarian provided uncontroverted testimony
 ALJ found “no overnight monitoring”
 Vision insurance audit
 All information regarding charges was in record
 Auditors could not find it
 Finding “optometrist sent in incorrect and unjustified charges”
 Medical Board LASIK case
 Informed consent records
 “Eval” versus “Reeval” in cataract case

39. Steven L. Simas
SIMAS & ASSOCIATES, LTD.
Government & Administrative Law
Sacramento -916.789.9800
San Luis Obispo -805.547.9300
w w w .simasgovlaw .com
ssimas@simasgovlaw.com