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What is in a pet medical record? In Ontario, the law spells it out: your pet's identification, your contact details, the date of every visit, the history including vaccinations, current weight, the vet's assessments with exam findings and test results, the advice given, every treatment and drug, consent for surgery, reports, and the fees. Other provinces have similar rules set by their own veterinary colleges.
Why should you care what's in the file? Because it helps you ask for the right parts, spot gaps when you switch clinics, and actually understand the notes when you read them. Below we go through each part, decode the usual shorthand, and explain how corrections and retention work.
What is in a pet medical record, according to Ontario law
Section 22 of Regulation 1093 under Ontario's Veterinarians Act lists what a companion animal's record has to contain. Here it is in plain words:
| Part | What it includes |
|---|---|
| Identification | Your pet's name or ID, species, breed, colour, age and sex |
| Client details | Your name, address and phone number, plus an emergency contact |
| Visits | The date of each visit |
| History | Past health history, including vaccinations |
| Weight | Current weight |
| Assessments | Exam findings, diagnostic tests and their results |
| Advice | The advice and recommendations given to you |
| Treatments | Every treatment, with each drug's name, strength, dose and quantity |
| Consent | For surgery: written consent, a note of verbal consent, or a note that you couldn't be reached |
| Reports and outcome | Reports from labs or specialists, and the final assessment |
| Fees | The charges, with drugs listed separately |
In Ontario, your pet's record must hold its history including vaccines, current weight, exam findings and test results, advice given, every drug with its dose, surgical consent and the fees.
How to read the exam notes
Exam notes are usually written in a set structure, which makes them easier to read once you know it. The College of Veterinarians of Ontario's guide to its medical records standard mentions SOAP and DAP formats, and says the record should show the vet's reasoning, not just a checklist.
The SOAP format
S is subjective, meaning what you told them: "eating less for three days." O is objective, what the vet measured, like weight, temperature, exam findings and test results. A is the assessment, the vet's read on what's going on, the possible causes, and how sure they are. And P is the plan: tests, treatments, medicines, advice and when to come back.
Shorthand you may see
You'll often spot abbreviations like BCS (body condition score), BID or SID (twice or once daily), PO (by mouth) and NAF (no abnormal findings). The CVO's guide notes that a bare "PE NAF" isn't enough on its own unless there's a defined protocol behind it. If something doesn't make sense, just ask the clinic. They explain this stuff all the time.
Can a record be changed?
Yes, a record can be updated and corrected, but the original always stays. Regulation 1093 says updates must be dated and must keep the earlier content, and for electronic records it requires an audit trail showing the date and time of each entry and any changes, with the original kept.
The CVO's guide adds that entries are initialled and dated, and that records are legal documents showing the vet's thought process. It also means a clinic can't wipe a record just because a client asks it to.
How long records are kept, and getting a copy
Ontario vets have to keep records for five years after the last entry, or two years after the vet stops practising if that comes first. The clinic keeps the original, but the CVO's guide says the information belongs to the client too. You can ask for a copy of any part, or the whole record. Your request doesn't need to be in writing, and a complete record should go to another vet within two business days.
For the step-by-step, see how to get your pet's vet records and who owns your pet's medical records. Lost some paperwork? Our post on lost pet vaccine records shows where to look.
What your copy may not include
A record sent between clinics is usually just the medical file, so you might have to ask separately for a few things:
- Full imaging, like the actual x-ray files instead of a written report (the CVO says radiographs should be included in a transfer if they're relevant)
- Lab reports as separate PDFs
- Your rabies certificate, which has its own required contents under Ontario's rabies regulation
- Signed estimates and consent forms
Keeping your own copy
When a new copy arrives, read it. Do the vaccines, dates, weight, allergies and medicines match what you remember? Are your contact details and emergency contact current? If something looks off, tell the clinic. Under Regulation 1093 the correction gets added with a date and the original stays visible, so nothing quietly disappears.
Your clinic's file is the official record, but having your own copy helps with new vets, kennels, insurance claims and travel. In the free PetGrid app you can upload a vet paper, and AI record reading suggests vaccines, medicines and allergies for you to confirm one by one. It all stays yours. You can download everything or delete it whenever you like, as your data explains.
Preguntas frecuentes
What information is in my pet's medical record?
In Ontario, it includes your pet's identification, your contact details, visit dates, history including vaccines, current weight, exam findings and test results, advice, treatments with drug doses, surgical consent, reports and fees.
Can I see my pet's full medical record?
Yes. The College of Veterinarians of Ontario says you can ask for a copy of any part or the complete record, and the request doesn't have to be in writing.
What does SOAP mean in vet notes?
SOAP stands for subjective, objective, assessment and plan. It's a common way vets structure each visit: what you reported, what they found, what they think, and what happens next.
Can a vet change or delete my pet's record?
A vet can add dated corrections, but the original entry has to be preserved, and electronic records need an audit trail. The CVO says a clinic can't purge a record because a client asks.
How long do vets keep pet medical records in Ontario?
Five years after the last entry, or two years after the vet stops practising if that's sooner.
En resumen
So what is in a pet medical record? Pretty much the whole story of your pet's care: who they are, their history and vaccines, their weight, what the vet found and thought, every treatment and drug, consent and fees. Corrections get added, never erased. You can ask for any part of it, and it's worth keeping a copy of your own.
The free PetGrid app makes that copy easy to build, and easy to share with the next clinic.
Guarde los historiales, las vacunas y las visitas de su mascota en un solo lugar seguro. La app PetGrid es gratuita para los dueños de mascotas, con o sin clínica.
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