A thorough and complete medical record is essential to the successful investigation and/or prosecution of an abuse case. It is considered evidence and even if the veterinarian is not called to testify, the medical record is a legal document that requires a higher degree of detail and precision than the practitioner may keep during the ordinary course of business.

• File medical records separately from other hospital files.
• Properly identify the animal.
  • This requires an accurate, complete, and detailed physical description, including the reproductive status of the animal, age, all colours, tattoos, distinctive markings or scars, cropped ears, docked tail, dewclaws, etc.
  • It should be noted in the record if the animal's age is a guess.
  • If the breed cannot be determined and is described as a mixed breed, then the description should include the weight, height and in some cases, even the nose-to-base-of-tail length. The incorrect description of an animal or injury can severely damage one's credibility and thus harm the case.
• Include complete information about the owner or caregiver if known- name, address, phone number, day and emergency contact information  - as well as the name of the animal
• Each veterinarian treating the animal should initial theiur respective entries in the record.
• Records should be legible.
• Mistakes should be crossed out with a single line. Avoid erasures or the use of products like "white-out" or "liquid paper" when making corrections in the record.
• Obtain a complete history, and determine whether there are other animals present in the household. If there are, ask for a description of their conditions from the owner  and record this for verification by an investigator.
• If the owner's other animals have been seen at your hospital, review their medical records  to see if there is evidence that may suggest previous abuse.
• The history should also include information about previously owned animals, their whereabouts, and the names of other veterinarians who may have treated them, if possible.
• Evaluate the animal's behaviour or mental status.
  • Regularly observe and monitor changes in behaviour and make appropriate notations in the medical record.
  • Changes in the behaviour or demeanour of the animal once it is away from the deprivation or abusive environment may be helpful to the case. Animals that are depressed and/or minimally responsive initially often exhibit dramatic behaviour changes as their physical and emotional health improves.
• Diagnostic and clinical tests are all part of the medical record. Samples sent to a commercial laboratory must be properly sealed and labeled. See Chain of Custody.
• When sending radiographs or images to a radiologist, be careful to avoid recording a diagnosis that may conflict with the radiologist’s interpretation.
• Daily updates should be included even if there are no changes in the animal's condition. Changes in the condition should be carefully described no matter how minor they may appear.

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