Content
Surgical and Non-surgical Procedure Records Requirements
Surgical, anesthetic, and non-surgical procedural records must include the following:
- Name and description of procedure
-
Animal identification (as appropriate)
- Non-rodent mammals must have individual records
- Other vertebrates (rodents, amphibians, reptiles, birds) may have group or batch records, if they are undergoing identical procedures
- Protocol number under which the procedure was performed
- Name of operator or experimenter
- Date and time the procedure was performed
-
List of physiologic parameters monitored during anesthesia, as appropriate for species, such as:
- Heart rate
- Respiration rate
- Temperature
- Assessment of anesthetic depth (e.g. lack of corneal or pedal withdrawal reflexes)
- Others as appropriate (e.g., blood pressure, end-tidal CO2, O2 saturation, capillary refill time)
-
Initial values of physiological parameters, and notations of any significant changes during the course of the surgery or procedure
- Intraprocedural monitoring must be documented as appropriate for procedure and situation, as determined by the Attending Veterinarian
- If not possible to record during the procedure, notations should be made during recovery (this applies to emergency situations only)
-
Time, route, and dose of all substances administered to the animal, initialed by the person who administers
- All drugs, including anesthetic gases
- Any experimental compounds
- Fluid support
-
Post-surgical/post procedural records
-
Immediate post-procedural recovery records (if applicable):
-
Must be maintained until the animal is recovered from anesthesia:
- Physiologically stable,
- AND able to maintain normal awake posture (e.g., sternal recumbancy for dogs, sheep; upright for nonhuman primates)
- Must be documented as appropriate for procedure and situation, as determined by the Attending Veterinarian
-
Must be maintained until the animal is recovered from anesthesia:
- Post-surgical period ends when sutures or wound clips are removed and all post-operative complications have been resolved
-
Immediate post-procedural recovery records (if applicable):
- If the surgery or procedure is terminal, records must still be maintained, and euthanasia and final disposition of the animal must be recorded
Sample forms are also available:
- Surgery Report Sample Form ( PDF | MS Word | WordPerfect Win )
- Treatment/Progress Record Sample Form ( PDF | MS Word | WordPerfect Win )
- Small Animal Anesthesia/Surgery Log Sample Form ( PDF | MS Word | WordPerfect Win )