RCVS clinical records: what your software has to make possible

The duty is on the person, not the product

RCVS supporting guidance opens by stating that veterinary surgeons and veterinary nurses must keep clear, accurate and adequately detailed records, and that clinical records should provide a complete and relevant account of the animal's clinical history, sufficient to support continuity of care, including examinations, treatments, test results, plans, who provided the care and advice given to the client (RCVS, read 15 August 2026). No system relieves anyone of that. What a system can do is make it easy or hard.

The amendment rule is the one to test in a demo

RCVS guidance states that clinical records may be amended to correct errors or factual inaccuracies, but that to maintain the audit trail, amendments should not remove or obscure the original entry, and should be dated, clearly show who made them and, where possible, be recorded alongside the original entry. That is a concrete, testable software behaviour. In a demo, write a note, save it, change it, and ask to see the original. If the original is gone, you have found something worth discussing before you sign.

What the six systems say about audit trails

Lupa

States that clinical records include a full audit trail, and that signed consent forms keep the full submission history linked to the pet and the appointment.

Digitail

Lists audit logs as a core feature, described as tracking system activity for compliance.

Provet Cloud

Medical records, treatment sheets and customisable forms are listed in every plan. No audit trail claim on the pages we read.

ezyVet

76 reporting views covering finances, clinical history, appointments, stock and customers. No audit trail claim on the pages we read.

IDEXX Animana

Patient medical records and weight history are listed. No audit trail claim on the pages we read.

AT Veterinary Systems Spectrum

A Clinical Notes module is listed among more than 120 modules. No audit trail claim on the overview page we read.

These entries record what appears on the supplier pages we read on 15 August 2026. An absence in this list means the supplier's public pages do not make the claim, not that the product lacks the function.

Three more things the guidance asks of a practice

• Copies on request. RCVS states that veterinary surgeons and veterinary nurses must provide copies of any relevant clinical records at the request of a client. Ask how long an export takes and what format it comes in.
• Handover. Relevant clinical information should be provided promptly to any vet taking over responsibility for a case, with appropriate documentation for referrals and re-directed cases.
• Client data. RCVS notes that client records will likely include personal data regulated under the UK GDPR and the Data Protection Act 2018, including the right of access via a subject access request. A subject access request against your PIMS is a practical test worth running once.

How long to keep records

RCVS does not set a single retention period. Its guidance says clinical records should be retained for as long as is necessary, taking into account legal and regulatory responsibilities, giving record keeping obligations for veterinary medicinal products as its example, and suggests also considering professional indemnity policy conditions, which may specify minimum retention periods. The hard numbers come from elsewhere: VMD requires medicines records for food producing animals to be kept for at least 5 years, and a Schedule 2 controlled drugs register for a minimum of two years after the last entry. Retention is therefore a practice policy question, and your PIMS needs to be able to hold to it.