![]() The AVMA has a great summary of these regulations here. You will also need to consider state and local laws about medical record release. ✅ Instinct EMR has a robust Communication Log to appropriately record this information. ![]() ![]() Under what circumstances and in what form the medical record or supporting documents such as radiographs, diagnostic results, or veterinarian's orders can be delivered to the client” (MR 29).The form in which the communication is delivered such as fax, telephone, email, or photocopy.Who approves the communication of the medical record.“The practice utilizes a written protocol for how medical record information is provided to the client. What does our hospital need to know about releasing veterinary records? □ AAHA standards also require practices to have a written protocol surrounding the maintenance of medical records, so make sure your hospital has a documented protocol and be sure to teach it as part of your onboarding process. Instinct helps meet these standards with a robust audit trail of everything your team does. Who has the authority to access the information” (MR 28).Information regarding the confidentiality of the medical records.“The practice utilizes a written protocol that details the maintenance of medical records. □ Maintaining a written medical record protocol Instinct makes it easy to assign different roles to team members, and each role has varying permissions to make compliance with this standard easier. Role-based security is a key requirement for your PIMS. “The Practice Information Management Software (PIMS) utilizes role-based security, allowing specific practice team members, classified within various positions, different levels of access to viewing, adding to and/or altering information” (MR 50.1). Instinct secures all practice data (encryption in transit and at rest) and follows security best practices around log in, passwords, and time-out standards throughout our applications. “Electronic medical record systems provide confidentiality and integrity by preventing unauthorized viewing or editing” (MR 44).Īccording to this particular standard, electronic medical record systems should prevent unauthorized viewing or editing. How can we ensure that veterinary patient records are secured appropriately?Ī few standards that apply here, and Instinct helps with them all. ✅ Instinct automatically abides by this standard, requiring amendments to be added if more than 24 hours have passed since notes were completed. Amendments/addendums are clearly recorded in an audit trail” (MR 48.1).įinished records should be closed within 24 hours, and amendments or addendums must be added afterward as relevant. “To ensure confidentiality and integrity, the electronic medical record system automatically closes record notations after a user-specified period (maximum of 24 hours). How long can records stay editable? □♂️ ✅ Records in Instinct are kept (and safely backed up) indefinitely, which means veterinary hospitals that use Instinct are automatically meeting this standard. You can find a handy AVMA guide to state laws here. Legal requirements for medical record retainment vary by state, but can extend up to 7 years past the last contact or treatment of a patient. ![]() Rather, it states that records must be kept long enough to ensure good patient care and comply with applicable legal requirements. “Medical records are retained for the length of time necessary to serve as resources for patient care, legal requirements, research, and educational tools” (MR 03).ĪAHA does not provide a specific length of time in this standard. For the most up-to-date and complete standards, please see AAHA’s published standards. We hope it helps your team to continue exceeding expectations. ![]() We're frequently asked about these standards, so we put together this guide to some of the more common questions. □ At Instinct, we’ve combed through these guidelines for you and use AAHA’s standards to inform our software development, which puts Instinct hospitals ahead of the curve. The medical recordkeeping standards in particular can be confusing, and they’re one of the more challenging groups of standards to meet. These hospitals are evaluated against a set of more than 900 quality standards that cover all aspects of veterinary medicine, from patient care to team training and, of course, medical recordkeeping. Many hospitals using Instinct are accredited or pursuing accreditation by the American Animal Hospital Association (AAHA). We're trying to think of everything when developing Instinct EMR. 10 Common Questions About Veterinary Medical Recordkeeping Standards Lyla Kotsch | | 6 min read ![]()
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