Medical Record Requirements

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* Take credit for the work you do

* If it isn't written down it didn't happen

Medical Records Forms
for Rodents

Anesthesia, Surgery, Post-Op

Post-Op Log Continuation

Note:
Some records can be combined

Information for an anesthesia record, surgery record, and post-anesthesia monitoring can often be combined into a single document for rodents; see example form

Rodent record requirements

Rodents' medical records convey necessary information to all people involved in their care and are indispensible for evaluating research outcomes. The Chief Campus Veterinarian, in consultation with the Senior Program Veterinarian for the School or College, has the ultimate responsibility and authority to determine the adequacy of animal records. The Senior Program Veterinarian will provide advice and guidance in the development and maintenance of medical records.

Information included in the rodent medical record:

  • Health record: General information including source, breed/stock/strain, color/markings, gender, birth date, and ultimate disposition (e.g., euthanized, transferred to another protocol).
  • Anesthesia record: Documentation of the anesthesia procedure, including recovery
  • Surgery record: Documentation of the surgery procedure
  • Post-anesthesia monitoring: Documents the initial period after an anesthetic event (+/- surgery) as well as the required monitoring period outlined in the animal use protocol.

Group vs. Individual Records

For the majority of procedures, surgeries, etc. conducted with rodents, a group record will suffice; however any rodent that receives unique treatment (e.g., treatment of a postsurgical infection) must have an individual record created or have this information clearly documented in the group record.

Location of rodent records

  • Readily available or accessible (near the rodent is best)
  • If portions of records are maintained outside the rodent area, they must be accessible within an hour of request
  • Acceptable formats for medical records
  • Electronic (must be accessible to veterinary staff and other inspection personnel)
  • Paper
  • Cage cards (for rodents with simple medical records)

Information must be

  • Legible
  • Current

Health Record

For day-to-day maintenance of rodents in a colony, a cage card will suffice for communicating timely and unambiguous identification of rodents and general information about them. At a minimum, cage cards must conform to Policy 2013-052-v Cage Labeling Requirements.

Cage Card

Required Information Name of the responsible investigator (PI)
Current name(s) and contact information for research personnel in case of emergency
Approved animal use protocol number
Any biohazards, toxic substances, or radioactivity the rodent has been exposed to


Strongly Recommended Information Pertinent dates (date of birth, date of arrival)
Source of the rodent (e.g., name of commercial vendor or institution, breeding colony)
Strain or stock of rodent (if known)

Lab Notebook/Logbook

Other procedures/manipulations must be documented in a lab notebook or other type of logbook. This information must be:

  • Readily available or accessible (near the rodent is best)
  • If portions of records are maintained outside the animal area, they must be accessible within an hour of request

Anesthesia Record

An anesthesia record should be generated whenever a rodent or group of rodents is subjected to an anesthetic event. This would include animals under general anesthesia (i.e. rodent is fully unconscious for a procedure) or for procedures where a local anesthetic (i.e. just a portion of the animal is rendered insensate).

Information for anesthesia record:

  • Title of procedure (e.g., “Ovariectomy”)
  • Date and time procedure is performed
  • Name of investigator
  • Animal use protocol number
  • Species of rodent
  • Name of anesthetist
  • Animal or group identification
  • Weight (required for injectable anesthetics—read RARC's guidance)
  • Any medications (e.g., fluids, reversal agents, other drugs), including dose, route and volume
  • Anesthetic(s) used:
    • Dosage, route, and volume for injectable anesthetics
    • Percentage gas and flow rates for inhaled anesthesia
  • Description of procedure/surgery

What to Monitor

Suggested Parameters Depth of anesthesia
  • Response of tail or toe pinch
  • Response to surgical stimuli (if applicable)
Respiration
  • Observe chest wall movement
Mucus membrane color, can be checked at
  • Muzzle, feet, ears, tongue


Other Possible Parameters Pulse, heart rate, direct or indirect blood pressure (cuff or Doppler)
Body temperature
Pulse oximetry
End tidal carbon dioxide

Surgery Record

A surgery record provides a complete description of the surgical procedure. The record begins with the start of the surgical procedure and ends at the time of wound closure. At this point continuing documentation transitions to postanesthesia monitoring.

Information for Record

  • Name of investigator
  • Date surgery is performed
  • Animal use protocol number
  • Animal or group identification
  • Name of surgeon
  • Complete description of the surgery including
    • The surgical approach
    • Description of the actual procedure
    • Type of suture material
    • Type of implant (if applicable)
    • Closure technique

Postanesthesia Monitoring Record

What to Do Right After Anesthesia/Surgery

Keep rodents warm and dry after anesthesia/surgery. Postoperative analgesics to prevent pain can be given at this time. Warmed IP fluids may be given to help raise core body temperature and speed recovery from anesthesia.

***After anesthesia/surgery an animal may only be left alone when it is awake and stable; the analgesia is provided per protocol; and the animal can lift its head and remain sternal or upright***

After Anesthetic Recovery

Rodents should be monitored according to the timetable in the approved protocol. Documentation of analgesia and postoperative monitoring must include:

  • Date and time
  • General observation of the rodent
  • Information on any analgesia or other drugs given in the postoperative period, including
    • Name of drug given
    • Dose, volume and route
  • Signature or initials of person conducting the postoperative monitoring and/or administering analgesia
Remember!

* Take credit for the work you do

* If it isn't written down it didn't happen

For help with medical records

General requirements

Medical records convey necessary information to all people involved in an animal’s care and are indispensable for evaluating research outcomes. The Chief Campus Veterinarian, in consultation with the Senior Program Veterinarian for the School or College, has the ultimate responsibility and authority to determine the adequacy of animal records. The Senior Program Veterinarian will provide advice and guidance in the development and maintenance of medical records for all vertebrate animals.

Information included in animal medical record

  • Health record:
    • General information about the animal including the animal’s final disposition, (e.g., species, breed, color, source, vaccination records, test results, and final disposition)
    • Basic information about the animals such as procedures performed and monitoring afterward, clinical treatments (e.g., antibiotics, analgesics, suture removal, etc.)
  • Anesthesia record: Documentation of the anesthesia, drugs, and monitoring during procedure, including recovery
  • Surgery record: Documentation of the surgery procedure
  • Post-anesthesia monitoring: Document the initial recovery period after an anesthetic event (+/- surgery) as well as the required monitoring period outlined in the animal use protocol.

Animals that require individual records

  • All vertebrate animals used in biomedical research with the exception of those that may be identified under group records as described below
  • Dairy cattle and horses used in agricultural research
  • Neonates can remain part of the dam’s record until individually identified or weaned

Animals that may have group records

  • Rodents, birds, amphibians, fish, or reptiles that receive the same treatment as a group (e.g., same surgery with the same anesthetic regimen, identical experimental compounds administered)
  • Agricultural herds with the exception of dairy cattle and horses
  • Any animal that receives unique treatment (e.g., treatment of a postsurgical infection) must have an individual record created or have this information clearly documented in the group record
  • For animals with simple medical records, information can be maintained on cage cards

Responsibility for maintaining animal records

  • Veterinarians and other veterinary staff
  • Principal investigators
  • Other designated employees such as facility managers and research staff

Location of animal records

  • Readily available or accessible (near the animal is best)
  • If portions of records are maintained outside the animal area, they must be accessible within an hour of request
  • Must be appropriately cross-referenced if maintained outside animal area

Acceptable formats for medical records

  • Electronic (must be accessible to veterinary staff and other inspection personnel)
  • Paper
  • Cage cards (for animals with simple medical records)

Information must be

  • Legible
  • Current
  • Consistent with current professional veterinary standards
  • Sufficiently comprehensive to demonstrate delivery of adequate veterinary care

Time frame for maintenance of medical records

  • At UW-Madison, we maintain animal medical records for 3 years after the death or disposition of the animal
Remember!

* Take credit for the work you do

* If it isn't written down it didn't happen

For help with medical records

Health records requirements

* All entries must by signed or initialed and dated. *

  • Animal identification (if applicable)
  • General information including source, breed/stock/strain, color/markings, gender, birth date or age, and ultimate disposition (e.g., euthanized, transferred to another institution, adopted)
  • Animal use protocol number
  • Description of any:
    • Procedures performed and monitoring afterwards
    • Illness
    • Injury
    • Behavioral abnormality
    • Experimental procedures with adverse outcomes
  • Description, date, and results of all observations, examinations, tests, or procedures, such as:
    • Vaccinations
    • Clinical laboratory results
    • Imaging/Reports
    • Anesthetic procedures
    • Surgeries
    • Necropsies
  • Treatments plans, including:
    • Diagnosis (if any)
    • Prognosis when appropriate
    • Type, frequency, and duration of treatment
    • Criteria and/or schedule for re-evaluation by veterinary staff
  • Results of routine health monitoring procedures (species-appropriate) such as:
    • Weight
    • Viral screening/serology
    • TB testing
Remember!

* Take credit for the work you do

* If it isn't written down it didn't happen

For help with medical records

Anesthesia records requirements

Basic Information

  • Name of investigator
  • Date and time procedure is performed
  • Animal use protocol number
  • Animal identification
  • Weight (required for injectable anesthetics)
  • Name of procedure (e.g., “percutaneous hepatic cannulation”)
  • Name of anesthetist
  • Name of surgeon (if applicable)
  • Preoperative medications (if applicable), including dose, route and volume
  • Anesthetic(s) used:
    • Dosage, route, and volume for injectable anesthetics
    • Percentage gas and flow rates for inhaled anesthesia
  • Description of procedure/surgery
  • Intra-operative/procedure medications or support (e.g., fluids, reversal agents, other drugs)
  • Anesthesia start and stop times

Anesthesia Monitoring Requirements*

  • These parameters should be monitored and documented at least every 15 minutes during a procedure:
    • Depth of anesthesia (e.g., response to tail pinch, palpebral response, response to surgical stimuli)
    • Heart and respiratory rates
    • Body temperature
    • Blood pressure, end-tidal CO2, O2 saturation, capillary refill time as appropriate

*Some of these parameters are not feasible in some species. Contact an RARC veterinarian or RARC trainers for further information.

Remember!

* Take credit for the work you do

* If it isn't written down it didn't happen

For help with medical records

Postanesthesia monitoring requirements

While still unconscious or semiconscious, all anesthetized animals must be examined at least every 15 minutes. Parameters to be assessed include:*

  • Animal's depth of anesthesia, behavior, position
    • Unconscious
    • Semiconscious
    • Conscious
    • Quiet Alert Responsive (QAR)
    • Bright Alert Responsive (BAR)
    • Lying on side
    • Sternal (i.e. lying on sternum)
    • Beginning to ambulate (i.e. moving around cage)
    • Moving around cage normally
  • Heart and respiration rates
  • Body temperature
  • Depth of anesthesia
  • Condition of surgical site (if applicable)
  • Time of extubation (if applicable)

After anesthetic recovery, animals should be monitored according to the timetable in the approved protocol. Documentation of analgesia and postoperative monitoring must include:

  • Date
  • General observation of the animal
  • If analgesia or other drugs are given in the postoperative period
    • Name of drug given
    • Dose, route, volume
  • Signature or initials of person conducting the postoperative monitoring and/or administering analgesia

*Some of these parameters are not feasible in some species. Contact an RARC veterinarian or RARC trainers for further information.

Remember!

* Take credit for the work you do

* If it isn't written down it didn't happen

For help with medical records

Surgery records requirements

A surgery record provides a complete description of the surgical procedure. The record begins with the start of the surgical procedure and ends at the time of wound closure, at which point continuing documentation transitions to postanesthesia monitoring.

Records must include:

  • Name of investigator
  • Date surgery is performed
  • Animal use protocol number
  • Animal or group identification
  • Name of surgeon
  • Surgery start/finish time
  • Complete description of the surgery, including:
    • The surgical approach
    • Description of the actual procedure
    • Type of suture material
    • Type of implant (if applicable)
    • Closure technique