Records for Medical Care

General requirements

Remember!

• Take credit for the work you do
• If it isn't written down it didn't happen

Medical records convey necessary information to all people involved in an animal's care. Medical records are indispensable for evaluating research outcomes. The Chief Campus Veterinarian, along with the Senior Program Veterinarian for the School or College, have the ultimate authority to determine what information will be kept in animal records. The Senior Program Veterinarian will provide guidance in the development and maintenance of medical records for all vertebrate animals.

Health record requirements:

• 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:
• 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

All entries must by signed or initialed and dated. Information must be:

• Legible
• Current
• Consistent with current professional veterinary standards
• Sufficiently complete to show that animals received adequate veterinary care

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) Note: at a minimum, cage cards must conform to Policy 2013-052-v, Cage Labeling Requirements

Medical Records Retention

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

Anesthesia records requirements

Basic Information

• Name of investigator
• Date and time procedure is performed
• Animal use protocol number
• Animal or group identification, species
• 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

Non-Rodent Anesthesia Monitoring Requirements*

• These parameters should be monitored and documented at least every 5-10 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.

Rodent Anesthesia Monitoring Requirements

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

Postanesthesia monitoring requirements

While still unconscious or semiconscious, all anesthetized animals must be examined at least every 5-10 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)

Keep animals 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, animals 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 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.

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