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Veterinary record retention Ontario: how long to keep records

Cet article n'est pas encore traduit en français : il est affiché en anglais.

Veterinary record retention Ontario rules come mainly from Regulation 1093 under the Veterinarians Act: medical records have to be kept for at least five years after the last entry, or until two years after the veterinarian stops practising, whichever comes first. Dispensing records also have a five year minimum, and federal narcotic rules add a two year requirement of their own for the records they cover.

Simple enough on paper. The trouble usually shows up years later, when someone needs a chart from a box in the basement. Below you'll find every requirement in one table, what counts as part of the record, what an electronic system has to do to meet the regulation, and how to dispose of records safely. The regulation and the College of Veterinarians of Ontario (CVO) standard are the authority, so check them, and your own legal advisor, before you change a retention policy.

Veterinary record retention Ontario periods at a glance

Veterinary record retention Ontario periods depend on the type of record. Here's what's written into the rules:

Minimum retention periods for Ontario veterinary records
RecordMinimum retentionRule
Medical records for each animalAt least 5 years after the last entry, or until 2 years after the member ceases to practise, whichever occurs firstReg. 1093, s. 22 (5)
Records of drugs dispensedAt least 5 years, or until the member ceases to practise, whichever occurs firstReg. 1093, s. 27 (2)
Record of attempts to contact a client about an animal left at the clinic5 years after the last attempt is documented, or 2 years after the member ceases to practise, whichever is shorterReg. 1093, professional misconduct rules
Records required under the Narcotic Control RegulationsAt least 2 yearsNarcotic Control Regulations (federal)

The safe working rule for an Ontario clinic: keep every patient's record for at least five years after its last entry.

Some records fall under more than one rule. A controlled drug entry can also be part of a patient's chart, for example. Keeping those for the longest period that applies avoids gaps. And remember these are minimums: the rules set a floor, not a date by which you have to delete anything.

What counts as part of the medical record?

The medical record is a lot more than the visit notes. Section 22 (1) of Regulation 1093 lists what a companion animal record has to contain, including:

  • Animal identification: species, breed, colour, age and sex.
  • The client's name, address and telephone numbers, and an emergency contact where relevant.
  • The date of each visit and the history, including vaccinations.
  • Current weight, assessments including the examination and diagnostic tests and their results.
  • Advice given, treatment and the drugs prescribed, dispensed or administered.

Since diagnostic results are part of the record, the lab reports and imaging behind an assessment should be kept as long as the chart. The CVO's medical records standard adds that records have to give an accurate, complete and up to date picture of the patient, and be accessible so another veterinarian can pick up the care.

What an electronic records system must do

An electronic records system has to meet the eight conditions in section 22 (6) of Regulation 1093, or Ontario doesn't allow it. Retention isn't only about keeping files around. The system has to keep them readable, intact and protected for the whole period.

  1. A visual display of the recorded information.
  2. Access to each animal's record by name or another unique identifier.
  3. Prompt printing of the recorded information.
  4. Display and printing of each animal's record in chronological order.
  5. An audit trail that records the date and time of each entry, shows changes, preserves the original content and can be printed separately.
  6. A password and other reasonable protection against unauthorized access.
  7. Automatic backups and recovery, or other reasonable protection against loss, damage and inaccessibility.
  8. A secure method so only the member can apply their electronic signature.

Ask any software vendor to show you each one, live, and ask what happens to your records if you leave. PetGrid's patient records keep an audit trail and preserve original entries, and import and export lets you take your data with you. If you want to see how the CVO checks all this on the day, our guide to veterinary medical records inspection walks through it.

Drug and controlled substance records

Drug records have rules of their own. Under section 27 of Regulation 1093, a member who dispenses a drug keeps a written record of the animal, the drug's name, strength and quantity, directions where needed, the date and the price. That record stays for at least five years, or until they stop practising.

Section 28 requires a controlled substances register showing the date, the client's name and address, the drug, strength and quantity, and the inventory left after each use. It also requires locked storage. Any loss or theft gets reported to police immediately and to the federal Minister of Health within 10 days.

Then there's the federal layer. The Narcotic Control Regulations require practitioners to keep the records those regulations call for for at least two years, and to produce them to an inspector on request.

Retention and the duty to share records

Retention also means you can hand a record over when asked. The CVO standard expects a complete record to be transferred within two business days when a client or another veterinarian asks for it. If your old files went to a storage unit with no index, two business days gets tight fast.

A few habits make it workable. Index archived records so any single chart can be found quickly. Run paper and electronic records on the same retention schedule. Test restoring a backup at least once a year, rather than finding out it doesn't work when you need it. And write down who can get into archived records, and log when they do.

Disposing of records at the end of the period

When the retention period is up, records have to be destroyed in a way that keeps them confidential, as the CVO standard requires. For paper, that's secure shredding. For electronic records, it's deletion from the live system and from the backups, by a method that can't be undone. Keep a log of what was destroyed and when.

Changing software? Make sure the old vendor deletes its copies once your data has moved. Our switching page explains how PetGrid handles a move.

Questions fréquentes

How long do vets have to keep records in Ontario?

At least five years after the last entry in the record, or until two years after the veterinarian ceases to practise, whichever occurs first. That's the rule in section 22 (5) of Regulation 1093 under the Veterinarians Act.

Do X-rays and lab results have to be kept too?

Yes, diagnostic tests and their results are part of the medical record under Regulation 1093. Keep them as long as the rest of the chart.

How long must controlled drug records be kept?

At least two years under the federal Narcotic Control Regulations, for the records they require. Ontario's Regulation 1093 separately requires dispensing records to be kept for at least five years, so keeping all drug records for five covers both.

Can an Ontario clinic keep records only electronically?

Yes, if the system meets the eight conditions in section 22 (6) of Regulation 1093. They include an audit trail that preserves original content, password protection, automatic backups and a secure electronic signature.

What happens to records when a clinic closes or a vet retires?

The records still have to be kept for the required period and stay available to clients and other vets. Decide who will hold them, and tell clients how to ask for copies.

Lire les questions et réponses pour les cliniques

En bref

Veterinary record retention in Ontario starts at five years after the last entry for medical and dispensing records, with federal narcotic rules on top. Knowing the number is the easy part. The real work is keeping every record complete, protected, findable and shareable for the whole stretch, then destroying it properly when the time comes.

PetGrid's records keep an audit trail and preserve every original entry. Our security page explains how we protect clinic data; after that, the best test is seeing it for yourself.

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Sources

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