CVMA | Documenting Abuse Cases

Documenting Abuse Cases

  1. Preserve and document the evidence. See also Collecting Evidence
    • Perform a complete physical examination (or necropsy)
    • Obtain a detailed history
    • Perform CBC, chemistry panel, fecal, urinalysis, etc
    • Take whole body radiographs to look for fractures in various stages of healing
  2. Maintain the chain of custody of the evidence. See Chain of Custody
  3. Take numerous photographs and/or video; and label appropriately. See Photography
  4. Maintain thorough, legible medical records as legal documents throughout the treatment period. If it becomes necessary to correct an entry, cross it out neatly; do not use white out or erase entries. See Medical Records.
  5. Store records securely. Trials may take place 1-2 years from the time the case is first seen.
  6. Prepare preliminary and final reports for law enforcement. See Veterinarians as Expert Witnesses