Cet article n'est pas encore traduit en français : il est affiché en anglais.
The CVO medical records standard requires every Ontario veterinarian to keep an accurate, complete and up-to-date record for each animal once a veterinarian-client-patient relationship exists, with the specific contents listed in section 22 of Regulation 1093 under the Veterinarians Act. For a companion animal, that means identification, client details, history and vaccines, weight, exam findings and diagnostics, advice, treatments with full drug details, surgical consent, reports, a final assessment and fees.
That's only the contents. The College also expects changes to be traceable, electronic systems to meet eight technical requirements, records to reach another vet within two business days, and everything to be kept for five years. It's spread across a regulation, a standard and a guide, so we've pulled it into one place, with a table you can hold a chart up against for a quick self audit.
Where the rules come from
The rules come from two documents that work together. Regulation 1093 (R.R.O. 1990, General) under the Veterinarians Act sets the legal minimum in sections 22 to 28. The College of Veterinarians of Ontario's Professional Practice Standard: Medical Records sets the practice expectations, and its Guide (revised September 2025) answers the common questions in plain language.
This isn't paperwork for its own sake. Under the same regulation, failing to make or keep required records is professional misconduct, and so is falsifying one.
What the CVO medical records standard requires in every companion animal record
Section 22(1) of Regulation 1093 lists what every companion animal record has to contain. Here's that list laid out so you can check a real chart against it.
| # | Required item | In practice |
|---|---|---|
| 1 | Animal identification: species, breed, colour, age and sex | Complete patient profile |
| 2 | Client's name, address and telephone numbers | Kept current at each visit |
| 3 | Emergency contact if the client may be away while the animal is in your care | Boarding, hospitalisation, surgery |
| 4 | Date of each time the vet sees the animal | Every visit, call or recheck |
| 5 | Health history, including vaccinations | Includes records from previous clinics |
| 6 | Current weight | Recorded each visit |
| 7 | Each assessment: physical exam data, diagnostics performed or ordered, and results | Specific findings, not just "normal" |
| 8 | Professional advice given, and to whom if not the client | Phone advice counts |
| 9 | All treatments and procedures, with drug name, strength, dose and quantity | Dispensed, prescribed and administered |
| 9.1 | Surgical consent: signed, or a note of oral consent and why, or why surgery proceeded without it | One of the three, every surgery |
| 10 | Copies of reports you prepared | Referral letters, certificates |
| 11 | A final assessment | Outcome of the case |
| 12 | Fees and charges, with drugs shown separately from advice and services | Invoice linked to the record |
A complete record isn't a long one. The CVO Guide says it needs enough detail for continuity of care and to show the veterinarian's reasoning behind each diagnosis and plan.
How much detail the CVO expects in a SOAP note
The CVO expects enough detail that another vet could follow your thinking. Its Guide calls medical records legal documents that represent the veterinarian's thought process, decisions and judgment, and it recommends SOAP or DAP formats.
In a SOAP note, the Subjective part holds the history of the presenting complaint and recent health status. The Objective part shows which body systems you examined, plus test results, and this is where shorthand trips people up: an abbreviation like PE-NAF isn't enough unless a referenced protocol says what the exam covered.
The Assessment is where your reasoning lives. It should show how you got to the diagnosis, with problem lists and differential or working diagnoses, updated as new information comes in. The Plan records what you'll do and what you discussed with the client.
The College actually encourages templates, protocols, checklists and problem lists as ways to keep records complete without making them long.
Changes, corrections and the audit trail
You can correct a record, but you can never make the original disappear. Since 2015, Regulation 1093 has required every update to be dated and documented so that the change, the date it was made, every earlier change, and the content before each change all stay identifiable. The Standard adds that an audit trail records the author and the date and time, and that the veterinarian must approve changes to original content.
What that looks like day to day:
- On paper, a single line through the error, with the date, initials and a reason
- Electronically, an audit trail that keeps the original, or a dated addendum with initials and a reason if the software can't audit
- With more than one vet or with locums, each entry carries the initials or code of the responsible vet
- Entries made right away, or as soon as possible after the encounter
The eight requirements for electronic record systems
Section 22(6) of Regulation 1093 only allows electronic records if the system has all eight of these characteristics. If you're comparing practice software, it doubles as a handy checklist.
- Displays the recorded information on screen.
- Finds each animal's record by name or another unique identifier.
- Prints the recorded information promptly.
- Displays and prints each animal's record in chronological order.
- Keeps an audit trail of the date and time of each entry and every change, preserves the original content, and can print the audit trail separately.
- Uses passwords and other reasonable protection against unauthorized access.
- Backs up automatically and can recover files.
- Lets only the vet apply their electronic signature to documents they must sign.
On top of those, the CVO Guide expects electronic records to be encrypted, with backups stored off site. Our security page explains how PetGrid handles each of these.
Transfers, retention and disposal
The timelines are short for transfers and long for keeping. These are the ones to know:
| Rule | Requirement |
|---|---|
| Transfer of complete records | Respond within two business days to a client or veterinarian request |
| Retention | At least five years after the last entry, or two years after the vet stops practising, whichever comes first |
| Radiographs | Kept as long as the patient record is kept |
| Practice closure | Records stored for up to two years, with clients and the College told how to get them |
| Client asks you to delete | Not allowed; the full record must still be retained |
| Disposal | In a way that protects client confidentiality |
One that catches clinics out: the Guide says an unpaid bill must not hold up the timely release of records needed for continuity of care.
How PetGrid supports the standard
In PetGrid's patient records, a saved note is never edited. A correction is a dated addendum with a reason, and the whole record prints as a PDF with its audit trail. Vaccines keep lot numbers and booster dates, vitals track weight over time, and anesthesia records lock when they're signed. Coming from another system? Switching explains how your records come across.
Questions fréquentes
What must be in a veterinary medical record in Ontario?
Section 22(1) of Regulation 1093 lists the contents for companion animals. They include identification, client details, visit dates, history and vaccines, current weight, assessments and results, advice, treatments with drug name, strength, dose and quantity, surgical consent, reports, a final assessment and fees.
How long must Ontario vets keep medical records?
At least five years after the last entry, or until two years after the veterinarian stops practising, whichever comes first. Radiographs are kept as long as the patient record is kept.
How fast must a clinic transfer records to another vet?
The CVO Professional Practice Standard expects a response within two business days when a client or a veterinarian asks for complete records to be transferred. An outstanding bill mustn't delay the release.
Can a veterinarian edit a medical record after it is saved?
A vet can correct a record but must never delete or obscure the original. Regulation 1093 requires each change to be dated, earlier versions to stay identifiable, and electronic systems to keep an audit trail.
Is PE-NAF enough to document a physical exam?
Not on its own. The CVO Guide says abbreviations like PE-NAF aren't sufficient unless the record references a protocol detailing what the exam covers.
What does the CVO require of veterinary software?
Regulation 1093 s. 22(6) sets eight requirements, including an audit trail that preserves original content, password protection, automatic backups, chronological printing and secure electronic signatures. The CVO Guide adds encryption and off-site backups.
En bref
Strip the CVO medical records standard down and it asks three things of you. Put the right contents in every record. Never let a change erase what came before. And keep records safe, ready to transfer within two business days, for five years. Hold a few charts up against the table above and you'll catch most gaps.
Want to see how a modern system handles addenda, audit trails and full record printing? We'd be glad to walk you through it.
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