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Medical Records Requirements
Health records are meant to convey necessary information to all people involved in an animal's care. They can be invaluable in evaluating research outcomes. The ultimate responsibility for determining adequacy of animal medical records rests on the Chief Campus Veterinarian, in consultation with the Attending Veterinarian. The Attending Veterinarian will provide advice and guidance in developing and maintaining medical records for all animal species.
Sample forms are also available:
- Surgery Report Sample Form ( PDF | MS Word | WordPerfect Win )
- Treatment/Progress Record Sample Form ( PDF | MS Word | WordPerfect Win )
- Anesthesia Record ( PDF | MS Word | WordPerfect Win )
- Post Anesthetic Monitoring Form ( PDF | MS Word | WordPerfect Win )
- Small Animal Anesthesia/Surgery Log Sample Form ( PDF | MS Word | WordPerfect Win )
Which animals must have records?
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Non-rodent mammals
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All non-rodent mammalian species used in research must have individual health records, including, but not limited to:
- Non-human primates
- Dogs
- Cats
- Rabbits
- Farm animals (e.g. sheep, pigs, cattle)*
- Infants can remain part of the dam's record until individually identified or weaned
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All non-rodent mammalian species used in research must have individual health records, including, but not limited to:
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Rodents and other vertebrates (e.g. birds, amphibians, reptiles)
- Group records are acceptable when groups of animals all receive the same treatment (e.g., the same surgery with the same anesthetic regimen, identical experimental compounds administered)
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Any animal or subgroup of animals treated differently from the rest of the group should have its own record, e.g. in the case of:
- Illness
- Trauma
- Adverse outcomes to experimental manipulations
- Group records may be appropriate for routine husbandry and preventive medical procedures
- For animals with simple health records, information can be maintained on cage cards
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Animals obtained for terminal procedures or tissue collection and housed short- term:
- Individual health records are not required unless there is veterinary intervention prior to termination
- Surgical and procedural records MUST be maintained on these animals
- Health records that arrive with the animal, and documentation of euthanasia and final disposition records must be maintained
What information is required in health records?
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Animal identification, if applicable
- Protocol assignment(s)
- Description of any:
- Illness
- Injury
- Distress
- Behavioral abnormality
- Experimental procedures and any adverse effects
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Dates, details, and results (if appropriate) of all medically related:
- Observations
- Examinations
- Tests
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Procedures, such as:
- Vaccinations
- Fecal examinations
- Radiographs
- Surgeries
- Necropsies
- Experimental procedures, including adverse effects
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Treatment plans, which should include:
- Diagnosis (if possible)
- Prognosis (when appropriate)
- Type, frequency, and duration of treatment
- Criteria and/or schedule for re-evaluation by the veterinarian
- Restrictions for the animal (such as exercise or feeding)
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Results of routine health monitoring procedures (as appropriate for species) such as:
- Weights
- Viral screening/serology
- TB testing
- All entries must be signed or initialed and dated
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Information contained in medical records must be:
- Legible
- Current
- Consistent with professional veterinary standards
- Sufficiently comprehensive to demonstrate the delivery of adequate veterinary care
Who can maintain health records?
- Attending Veterinarian
- Investigators
- Other designated employees (e.g. facility managers)
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If records are located in more than one place, they must be:
- Appropriately cross-referenced
- Readily available or accessible (near the animal is best)
- Complete with all required information
What are acceptable health record formats?
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As long as all the above information is available, many formats are acceptable:
- Electronic
- Paper
- Cage cards (e.g. for rodents)
How long must records be maintained?
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USDA requirements
- Dogs and cats - records must be maintained for 3 years after the disposition or death of the animal
- Other animals - at least one year after the animal's disposition or death
- NIH requirements - records (data and fiscal) must be maintained for 3 years after the end of the grant
* Agricultural animals used in agricultural research (not biomedical research)
- Dairy cattle and horses - must have medical records as for other non-rodent mammals as described above
- Other herds (beef, swine, sheep, etc.) - Records can be kept as described above for rodents and other vertebrates (excepting cage card use)