In this episode, Jeff Blea, DVM, discussed the dangers of veterinary medical records that don’t measure up to state regulations. Veterinary medical record regulations dictate how patient information must be documented, stored, and released. These regulations are state-specific, and they aim to ensure patient confidentiality, proper patient care, and legal compliance. Key aspects in most states’ regulations include record content, retention periods, confidentiality, and disclosure requirements. 
Blea emphasized the need for complete, factual, accurate, and contemporaneous medical records. He reminded listeners that state veterinary medical boards exist to protect the public. If your state board receives a complaint from the public, it has the right to access all your medical records during its investigation. Therefore, it’s important for veterinarians to be familiar with their state’s Veterinary Practice Act to ensure their records meet its regulations. In many states, each dispensed medication must be accompanied by a documented medication consultation. Further, many states mandate that at every visit, the veterinarian must note the horse’s vital signs, weight, identification (microchip, tattoo, or brand), and other pieces of data.
Blea discussed the necessity of never altering a record after the fact, documenting all communication, obtaining and documenting consent for all procedures and treatments, and never promising a particular result. Recognizing the burden such records pose to busy equine veterinarians, Blea said technology, technicians, and templates can be a great help and shared examples of how each can increase efficiency. In closing, he said, “Remember, if it isn’t documented in writing, it didn’t happen.”
About Dr. Jeff BleaÂ
Jeff Blea, DVM, was a racetrack practitioner and partner in von Bluecher, Blea, Hunkin, Inc., a five-veterinarian Thoroughbred practice in Southern California, for decades. He served on the AAEP Board of Directors from 2003-2005 and as the 2014 AAEP President. His AAEP service also included many committee and task force assignments, as well as being an On Call spokesperson. In addition, he has served on the Grayson Jockey Club Research Committee, the UC Davis Intramural Grant Research Committee, and on the boards of the Southern California Equine Foundation, the Racing Medication and Testing Consortium (RMTC) Equine Health and Safety Advisory Board, the Dolly Green Research Foundation, and California Retirement Management Account (CARMA). Currently, Blea is the equine medical director of the California Horse Racing Board. 
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