A needs assessment A treatment plan
• •
• Ongoing record of each treatment given per appointment including date of treatment, areas treated, findings, who provided treatment • At least a brief version should be sent to the referring veterinarian within a reasonable time following therapy, both as a professional courtesy and to keep the vet informed of the any procedures and progress
3. Identification
Every part of the health/financial records must be identified/referenced to whom it belongs (client #/name).
4. Entries
All entries must be in ink if hand-written, dated and signed by (or name noted) the person who provided treatment. If entries made are digital, a back-up copy must be saved.
5. Record maintenance
All client’s records must be kept for seven years following their last appointment. (If the client is under 18 years of age following their last appointment, records must be kept until the day the individual would have turned eighteen.) Records may be kept by means of an electronic or optical storage system. Records must be kept in a manner which ensures they are secure from loss, tampering, interference or unauthorized use or access.
6. Destruction of Records
Done in a manner which ensures the client's confidentiality (i.e. burning or shredding).
7. Inspection of Records/Premises
• The client has the right to see his or her own records/files
• The client has the right to inspect the R.E.M.T.'s clinic (if applicable) prior to treatment as part of INFORMED CONSENT
• The IFREMT has the right to inspect any/all client records, and R.E.M.T.'s clinic (if applicable) at any time, if there is reasonable cause
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