Veterinarians may be asked to certify that veterinary services have been provided to either an animal or a group of animals. The certification may be in the form of a certificate, a report, or a copy of the medical records.

This has been commonplace in large animal and equine areas for many years.  Vaccination certificates were the most common example in small animal practice until the increased uptake of pet insurance.

Just as a reminder, the Veterinary Practitioners Code of Professional Conduct (Code) (clause 17) states (emphasis added) that:

• A veterinary practitioner must NOT certify to any fact within his or her professional expertise or knowledge, or that a veterinary service has been provided, unless the veterinary practitioner has PERSONAL KNOWLEDGE of the fact or has PERSONALLY PROVIDED, or SUPERVISED the provision of, the veterinary services concerned
• Any certification by a veterinary practitioner must contain such detail as is necessary to ensure that it is COMPLETE and ACCURATE and that the meaning is clear.

The Code (clause 15) also states that records of the services provided must be legible and in sufficient detail to allow another veterinarian to continue treatment of an animal; if the record is altered the alteration must be clearly identified in the record as such; and that records must be kept for at least 3 years.

The record must clearly identify the owner or client and provide full details of the animal including such matters as name, breed, sex, colour and microchip, tattoo or brand.

Here are a few different issues regarding certification confronting veterinarians:

1.    You cannot verify that a dog is desexed if you did not personally provide, see or supervise the provision of this service but you can sign a copy of a record of a desexing procedure from your practice as being a true and correct copy of a record that you have sighted.

2.    You cannot alter a record such as what service was provided, the date the service was provided or to delete a service provided for the purpose of assisting a client with an insurance claim but you can alter a record to correct a mistake if you clearly identify the alteration.

3.    If you add extra charges such as time for completing forms because an animal is insured, these fees should be clearly itemised.  Simply increasing some or all of the charges without identifying the increases, based on the fact the animal was insured, could be seen by the Board as misleading or deceptive if a complaint was lodged.  You may also find yourself the subject of separate legal action.

4.    You should not ask clients to pre-sign insurance claim forms as you may be exposed to claims of certifying services that may have been unnecessary. Your obligation to obtain informed consent for services remains irrespective of whether an animal is insured.

5.    You should not provide veterinary services for your own animals and then submit an insurance claim unless this is unavoidable. It is advisable to refer your own animals to another veterinary practitioner if you will be seeking an insurance claim for these services.

Most importantly, you must not under any circumstances be persuaded or coerced by a client or colleague to alter an animal’s accurate records.

The Code of Professional Conduct for Veterinary Surgeons  issued by the Royal College of Veterinary Surgeons has some useful information under section 9, Animal insurance.