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The veterinary profession has always been vulnerable to malpractice actions because of the general low quality of its medical records. As the profession advances, the medical records must also advance in their quality. In this light, it is important to recognize that radiographs and radiographic reports are a part of the medical record. The legal rules that apply to medical records also apply to the radiographs and the radiographic reports.
Medical records are considered the property of the hospital or the practicing veterinarian. The owner probably does not have a right to the radiographs or the radiographic report; however, he does have a right to an abstract or explanation of the medical record which could include a description of the radiographic study and the radiographic findings. Ownership of radiographs in a veterinary practice in California was the subject of an opinion No. CV 74/168 IL dated September 27,1974 by the Attorney General of the State of California. That opinion stated that "it is our conclusion that, absent an agreement to the contrary, a veterinarian who takes x-ray films of an animal owns them, . . ."
However, the opinion further stated that "the veterinarian may be under a moral or ethical duty to give these films or copies thereof to another veterinarian if the animal's owner so desires." Therefore, if a practitioner is asked by the owner to provide a second veterinarian with the opportunity to evaluate a radiographic study he must do so.
Many requests to review radiographs come from other than the owner of the animal who ordered the radiographic examination. A question arises concerning your response to the request of a new owner to have a radiographic study sent to another veterinarian when the radiographic study was originally ordered by a previous owner. Another area of question involves the desire by a veterinarian who is presently serving a potential owner to review a series of radiographs you made for the current owner. The problem in these cases is your response to a request from someone other than the owner who ordered you to perform the radiographic examination. It is possible that your affirmative response to one of these questions might provide another party with information concerning the animal that might give reason to cancel a proposed sale. To be on the safe side, you should divulge the findings from a radiographic study only to the owner or his agent.
Remember that the radiographs as components of the case record are of no value unless they are identified in such a way that there is no question concerning the identity of the animal examined, the anatomical part examined, and the date on which the examination took place.
There is the mistaken idea that medical records only have a value in support of an allegation brought against a veterinarian. It should be realized that a good radiographic study may provide the evidence necessary to disprove an allegation and refute charges of malpractice.
Laws rarely state the specific period of time that radiographs must be retained. A period of five years is often used for physicians and this would seem to be an acceptable period of time for veterinarians. Study of earlier radiographs for referral purposes is often of value for periods extending to three to five years. After that time, there is little value in having radiographs available for reexamination. The storage of all radiographs for a five year period usually does not create space problems for the average practitioner.
By definition, the medical record includes all information which a veterinarian might compile about a client's animal. Laboratory reports and radiographs are a part of that record together with any notes made by attendants who, under the direction of the veterinarian, had any connection with the animal. These records serve as evidence of the ability of the veterinarian to promptly and accurately record basic information concerning the patient. A part of the record keeping is a systematic method of filing radiographs so that retrieval is easy. In the absence of specific statutes relative to the keeping and destruction of certain records, the veterinarian can refute any aura of guilt which might settle on him from an apparent selective and intentional destruction of records if he has a definite policy regarding the records and follows that policy. Remember that the physical property in medical records is the property of the veterinarian but the information contained within the records is the property of the client.
