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Records for Medical Care

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General requirements

Remember!

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:

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

Animals that require individual records

Animals that may have group records

Responsibility for maintaining animal records

Location of animal records

Acceptable formats for medical records

Medical Records Retention

Anesthesia records requirements

Basic Information

Non-Rodent Anesthesia Monitoring Requirements*

*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

Respiration

Mucus membrane color, can be checked at

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:*

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

*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:

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