What must a veterinary medical record include?

Under art. 9 of CFMV Resolution 1.321/2020, each visit records the date, time and place, the veterinarian, the owner's account, the general condition and parameters, the findings, the presumptive and the definitive diagnosis, the procedures with daily progress and the people responsible, the vaccines and the test reports.

How long does a vet clinic keep the medical record?

For at least 5 years after the date of the last visit, even if the animal dies (CFMV Resolution 1.321/2020, art. 9, § 3).

Does the owner have the right to a copy of the pet's record?

Yes. A request from the person responsible for the animal is fulfilled within 5 business days. If that is not possible, the responsible veterinarian (responsável técnico) explains why in writing and sets a new deadline of up to 30 business days (art. 9, § 1, as amended by CFMV Resolution 1.653/2025).

Which consent forms must the veterinarian get from the owner?

Art. 10 of CFMV Resolution 1.321/2020 lists 10 documents, such as the forms for tests, surgery, anesthesia, hospitalization, euthanasia and removal without discharge. The act depends on presenting the form in advance and on the owner's signature, except in imminent risk of death.

Is an electronic veterinary record valid?

Yes, if the system ensures the security, authenticity, confidentiality and integrity of the information, as well as its storage (CFMV Resolution 1.321/2020, art. 3, § 2). Check with your CRMV which signature method is accepted.

Veterinary medical records: what CFMV Resolution 1.321/2020 requires and which forms the owner signs

By Victor Ferreira · October 26, 2026 · 7 min read

The veterinary medical record is the dated log of each visit of the pet, signed by the veterinarian. It is kept for at least 5 years after the last visit. CFMV Resolution 1.321/2020 says what it records and lists 10 forms the owner signs before the act. An electronic record is valid when the system ensures integrity and authenticity.

What is a veterinary medical record, under the rules?

It is the document that tells, in chronological order, everything done with the animal. CFMV Resolution 1.321/2020, art. 2, VIII, defines the record as a written and dated document, with no erasures or alterations. It is issued and signed only by the veterinarian.

The same item says what goes in: outpatient and clinical visits, vaccines, tests and surgeries. And it requires that the authenticity and integrity of the information be ensured.

Two practical consequences for anyone using software:

No erasures means no editing. In the system, the log of a visit should not be deleted or rewritten. A correction goes in as an addendum, with date, time and author.
Everything is part of the record. Under art. 3, the documents issued by the veterinarian are part of the patient's record: certificates, consent forms, prescriptions and reports.

The resolution has been in force since May 4, 2020 and was amended by CFMV Resolution 1.653 of June 26, 2025.

What must the record log at each visit?

Art. 9 lists ten items for each visit. This is the list, with a way to check it in the clinic's system:

Item in art. 9	What to record	How to check in the system
I	Date, time and place of the visit	Filled in automatically when the visit is opened
II	Veterinarian who saw the patient	Tied to the login, not typed
III	Accounts and information from the person responsible for the animal	Its own field in the history
IV	The animal's general condition and measured parameters	Weight, temperature and anything else measured
V	Findings from the history, the anamnesis and the tests	Free-text field, with the history in view
VI	Presumptive diagnosis	Field separate from the definitive one
VII	Definitive diagnosis, when there is one	Can be added later, as an addendum
VIII	Procedures, with daily progress, date, time and those responsible (name and CRMV)	Each inpatient dose with the time and who gave it
IX	Immunizations given	Linked to the vaccination card
X	Copy of each supplementary test report	Attached to the visit

Item VIII matters most for hospitalized patients. The wording of Resolution 1.653/2025 requires the full name and CRMV number of each professional who performed the procedure. On the inpatient board, this means recording who gave each medication, not only that it was given.

The documents must also identify the owner, with full name, CPF and address (art. 3, VII). And the patient, with name, sex, breed, age and markers such as a microchip (art. 3, VI).

The vaccination card has its own rule in art. 6: the date of each vaccine, its name, batch, manufacturer, dose, manufacturing and expiration dates, and the planned revaccination date. A system that links the vaccine given to the inventory lot fills this in without typing.

How long to keep it and how to give the owner a copy?

Keep it for at least 5 years after the date of the last visit, even if the animal dies (art. 9, § 3). Deliver the copy the owner requests within 5 business days (art. 9, § 1).

The delivery rules, as amended by Resolution 1.653/2025:

Normal deadline: up to 5 business days from when the request is logged, on paper or in digital form.
Longer deadline: if that is not possible, the responsible veterinarian explains why in writing and sets a new deadline of up to 30 business days.
Third-party test ordered by the clinic: such as a CT scan or histopathology, up to 30 business days.
Who can request it: the person responsible for the animal on file, or someone they authorize, to preserve confidentiality.
Proof of delivery: the copy goes out with a receipt.

§ 2 of the same article covers loss. The responsible veterinarian notifies the owner and opens a new record noting what happened. If applicable, they file a police report and notify the CRMV.

The other documents, such as certificates and consent forms, are issued in 2 copies, physical or digital: one for the owner and one for the file (art. 3, I). The record, the vaccination card and the health certificate are the exception.

Which forms must the owner sign?

Art. 10 lists 10 authorization or consent documents. Under § 1, the act depends on presenting the form to the owner in advance and on the owner's signature.

Form (art. 10)	When the clinic uses it
I. Consent for tests	Before tests that require authorization
II. High-risk therapeutic procedure	Treatment with risk of loss of function or death
III. Removal of a deceased animal's body	When the owner takes the body
IV. Surgical procedure	Before every surgery
V. Hospitalization and clinical or post-surgical treatment	On admission
VI. Anesthetic procedures	Before anesthesia
VII. Euthanasia	Before the procedure
VIII. Removal without medical discharge	When the owner takes the pet against advice
IX. Donation of the body for teaching and research	When the owner donates
X. Clinical research	When the animal joins a study

Three rules complete the article:

Emergency. With imminent risk of death or permanent disability, the veterinarian treats without the form. In the record, they log the refusal or the impossibility of getting it (§ 3).
Removal without discharge. If the owner refuses to sign, the veterinarian logs it in the record. Two witnesses who saw the refusal sign the form (art. 11, § 1).
Templates. The resolution's annexes contain the templates, on the CFMV website, and the clinic can adapt them as long as it keeps the minimum content (art. 12).

Is an electronic record valid?

Yes, if the system meets art. 3, § 2: security, authenticity, confidentiality and integrity of the information, as well as storage and sharing of the data.

When you choose or evaluate a system, this becomes a checklist:

Log of who did what. Each visit, addendum and access records author, date and time.
No deleting. A closed visit is not edited; a correction goes in as an addendum.
Permissions by role. The assistant sees what they need for the medication, without the owner's financial history and contact details. The LGPD, in art. 46, requires security measures against unauthorized access.
Backup and export. The 5-year retention applies even if the clinic changes systems.
Signature. The resolution refers to a signed document. Between private parties, MP 2.200-2/2001, art. 10, § 2, allows other means of proving authorship and integrity, as long as the parties accept them. Check with your CRMV and your legal team the method used for each form.

How CERNE solves it

CERNE offers the medical record, hospitalization and consent forms in the same system, with the logging the resolution requires.

The pet's record. History, tests, prescriptions and attachments from each visit in the pet's file, with the veterinarian tied to the login.
Hospitalization with times and progress. Each medication has a time and the person who gave it, and the shift's progress note stays in the record.
Vaccine linked to the lot. The vaccine given is deducted from inventory with lot and expiration date, and the next dose is scheduled.
Consent form by link. The owner reads the form and approves through the link, and the approval is recorded with date and time, alongside the estimate.
Controlled access. The assistant sees the pet, the prescription and the medication time, without the owner's phone number or address. Each access to the record is logged.

The veterinary package uses modules that already run for other CERNE clients. These are the schedule, the board with an owner and a deadline for each task, and client approval by link. See the workflows on the vet clinics page and the cards for each function. For estimates and collection, see late payments at the vet clinic.

Start with an assessment

The rules are the same for every clinic. What changes is where your record slips: on paper, on WhatsApp or in a system that does not log who did it. Start with an assessment of your operation: our team reviews the record and the consent forms with you. Book the assessment.

Frequently asked questions

What must a veterinary medical record include?: Under art. 9 of CFMV Resolution 1.321/2020, each visit records the date, time and place, the veterinarian, the owner's account, the general condition and parameters, the findings, the presumptive and the definitive diagnosis, the procedures with daily progress and the people responsible, the vaccines and the test reports.
How long does a vet clinic keep the medical record?: For at least 5 years after the date of the last visit, even if the animal dies (CFMV Resolution 1.321/2020, art. 9, § 3).
Does the owner have the right to a copy of the pet's record?: Yes. A request from the person responsible for the animal is fulfilled within 5 business days. If that is not possible, the responsible veterinarian (responsável técnico) explains why in writing and sets a new deadline of up to 30 business days (art. 9, § 1, as amended by CFMV Resolution 1.653/2025).
Which consent forms must the veterinarian get from the owner?: Art. 10 of CFMV Resolution 1.321/2020 lists 10 documents, such as the forms for tests, surgery, anesthesia, hospitalization, euthanasia and removal without discharge. The act depends on presenting the form in advance and on the owner's signature, except in imminent risk of death.
Is an electronic veterinary record valid?: Yes, if the system ensures the security, authenticity, confidentiality and integrity of the information, as well as its storage (CFMV Resolution 1.321/2020, art. 3, § 2). Check with your CRMV which signature method is accepted.

CERNE for Veterinary clinics. Schedule, records, vaccines, inpatient care with owner updates, POS, inventory and invoicing in one system. AI works inside the operation, and a team works alongside your management. See how it works or start with an assessment of your operation.

Sources

Victor Ferreira · Partner at IF Soluções and responsible for CERNE's architecture: the modules many companies share, the API integrations with the systems clients already use, data and security. Makes sure a workflow built for one client becomes a module that serves other markets.