Clinical and client records including diagnostic images and similar records, are the property of, and should be retained by, veterinary surgeons in the interests of animal welfare and for their own protection. Although clients do not own their clinical records, they have the right to access information about themselves under data protection legislation as well as under professional guidelines set by the RCVS.
The GDPR gives individuals the right to access their personal data. To clarify, the GDPR relates to personal data - data about an individual person. Information about an animal is not personal data and is outside the scope of the GDPR. Unless the subject access request is excessive or repetitive, a copy of the information must be provided free of charge, and the information should generally be provided without delay and no later than one month after receipt of the request. This is subject to certain exceptions. Care must be taken where the disclosure would involve disclosing another individual's personal data or confidential information. In such cases, consider seeking legal advice or read the Information Commissioner's Office's (ICO's) guidance on subject access requests. Veterinary surgeons and veterinary nurses may need to seek the consent of other people to the disclosure of their personal data, or consider redacting it where appropriate.
Under RCVS guidelines, at the request of a client, veterinary surgeons and veterinary nurses must provide copies of any relevant clinical and client records. This includes relevant records which have come from other practices, if they relate to the same animal and the same client, but does not include records which relate to the same animal but a different client.
In many cases it will be made clear to clients that they are not being charged for radiographs or laboratory reports, but for diagnosis or advice only. In situations where images are held on film, the film remains the property of the practice, with the client being charged for diagnosis or advice. In this situation, copies should still be provided in response to a request, wherever possible. Where images are held digitally, clients are also entitled to a copy.
Relevant clinical information should be provided promptly to colleagues taking over responsibility for a case and proper documentation should be provided for all referral or re-directed cases. Cases should be referred responsibly (Referrals and second opinions). Additional requests for information should also be dealt with promptly.
