Medical Records for Non-USDA Covered Species

What species are not covered by USDA?

• • Mice, rats, and birds (unless wild caught); reptiles, fish, and amphibians (cold blooded); animals used for agricultural research

An animal’s medical record includes (but is not limited to):

• • Health record
  • Anesthesia record
  • Surgery record

People responsible for maintaining animal records: 

• • Veterinarians and other veterinary staff
  • Investigators and laboratory staff
  • Other designated employees, such as facility managers and research staff

 You may maintain records in three different formats:

• • Cage cards
    • Note: at a minimum, cage cards must conform to “Cage Labeling Requirements” (Policy UW-4104)
  • Electronic
  • Paper

It is expected that medical record entries are current, accurate, and complete. Records must be readily available and accessible when veterinary staff or inspection personnel request to see them.

At a minimum, a copy of the anesthesia/procedure records must be in the animal’s medical record by the morning after the anesthetic procedure.

When making an entry into a record:

• • Sign or initial and date each entry
  • Print legibly
  • Use ink (blue or black)
  • Strike through mistakes with a single line
    • Initial and date the correction

Rodents, birds, amphibians, fish, or reptiles that receive the same treatment (e.g., identical experimental compounds administered) may have a group record instead of an individual record for each animal.

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Health Records 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, treatment plans, and monitoring afterwards (per protocol)
    • Remember to keep track of adverse outcomes such as those that result in illness, injury, or behavioral abnormalities
    • Include date and adverse outcomes. Contact an RARC veterinarian if adverse outcomes occur (Policy UW-4103).
  • Protocol-required monitoring, such as:
    • Weight or body condition score
    • Activity level
    • Appearance of animal
    • Tumor measurement

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Anesthesia Record

When administering anesthesia for procedures lasting longer than 15 minutes, you must fill out an anesthesia monitoring record. Labs may create their own anesthesia monitoring record or use the anesthesia form templates found on this page. You may use a form combining the anesthesia and procedure (surgical or non-surgical) or use separate forms. At a minimum, a copy of these anesthesia/procedure records must be in the animal’s medical record by the morning after the anesthetic procedure.

Monitor and document these parameters at least every five to 10 minutes during a procedure.

Best practice is to include the following in your anesthesia records (ensure you are following parameters outlined in your lab’s animal care and use protocol):

• • Date 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 or person performing procedures (if applicable)
  • Preoperative medications (if applicable)
    • Name of drug given
    • Dose (total mgs given), route, and volume (mls)
  • Anesthetic(s) used
    • Dosage, route, and volume for injectable anesthetics
    • Percentage gas and flow rates for inhaled anesthesia
  • Intra-operative/procedure medications or support (e.g., fluids, reversal agents, other drugs such as analgesics, heat support)
    • It is recommended that analgesics be provided at the beginning of anesthesia or immediately after finishing the procedure, before the animal wakes up.
  • Anesthesia start and stop times
  • Procedure start and stop times

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Suggested Parameters for Non-USDA Anesthesia Monitoring

• • Before beginning any procedure, check the depth of anesthesia (e.g., palpebral response, jaw tone, toe or tail pinch).
  • A surgical plane of anesthesia is required before beginning an anesthetic procedure.
  • During the procedure, at a minimum, you must monitor for respirations.

Other possible parameters to monitor during anesthesia:

• • Heart rate
  • Blood pressure
  • Mucus membrane color (can be checked at muzzle, feet, ears, or tongue)
  • O₂ saturation (recorded by pulse oximeter)
  • End-tidal CO₂
  • Body temperature
    • Animals may get cold under anesthesia; using an approved heat source during and after the procedure can help recovery. If you mention use of a heat source in the protocol, you must use one.
    • Always keep a barrier between the animal and the heat source (example: a towel).

After an anesthetic event, monitor the animal until fully recovered, i.e., until the animal can normally move around the cage.

Providing an approved heat source under the recovery cage will aid in optimal recovery. Place the heat source under half of the recovery cage, providing a heated and unheated area to allow the animal to self-regulate temperature.

Contact an RARC veterinarian for assistance identifying which parameters are applicable for your species.

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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 once the wound is closed, at which point continuing documentation transitions to post-anesthesia monitoring. All of this information may be included on a combined document.

Best practice is to include the following in your surgery records (ensure you are following the parameters outlined in your lab’s animal care and use protocol):

• • Date surgery is performed
  • Animal use protocol number
  • Animal or group identification
  • Species
  • Name of surgeon
  • Surgery start/finish time
  • Description of procedure/surgery
    • The surgical approach
    • Description of the actual procedure
    • Type of suture material (if applicable)
    • Type of implant (if applicable)
    • Closure technique
  • Intra-operative/procedure medications or support (e.g., fluids, reversal agents, other drugs such as analgesics, heat support)
    • It is recommended that analgesics be provided at the beginning of anesthesia or immediately after finishing the procedure, before the animal wakes up.

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Post-Anesthesia Monitoring Documentation

Monitoring Requirements Immediately After Procedure:

While still unconscious or semiconscious, all anesthetized animals must be monitored and observations must be documented at least every five to 10 minutes.

In the case of rodent species with a group record, you can keep either separate records on recovery or a group record.

Contact an RARC veterinarian for assistance identifying the parameters applicable for your species.

Parameters to be assessed include:

• • Animal's depth of anesthesia, behavior, position
    • Unconscious
    • Semiconscious
    • Conscious
    • Lying on side
    • Sternal (i.e. lying on sternum)
    • Beginning to ambulate (i.e. moving around cage)
    • Moving around cage normally
  • Respiratory effort and quality- the recovery breathing quality and effort should be close to that of the animal’s rate, quality, and efforts before surgery
  • Body temperature
    • Animals may get cold under anesthesia; using an approved heat source after the procedure can help recovery. If you mention use of a heat source in the protocol, you must use one.
    • Always keep a barrier between the animal and the heat source (example: a towel).
    • Providing an approved heat source under the recovery cage will aid in optimal recovery. Place the heat source under half of the recovery cage, providing a heated and unheated area to allow the animal to self-regulate temperature.
  • Time of extubation (if applicable)

After anesthesia/surgery, an animal may only be left alone when:

• • The animal is awake and stable
  • The analgesia has been provided per protocol
  • The animal can lift its head and remain sternal

Once sternal, the animal must be checked and observations must be documented every 30 minutes until the animal is standing without support.

Continued Monitoring Requirements (days following procedure):

In the days after anesthetic recovery, animals must be monitored according to the timetable in the approved protocol. Documentation of monitoring must include:

• • Date and time of observation
  • General observation of the animal
  • Condition of surgical site (if applicable)
  • Other monitoring parameters as described in the animal care and use protocol (i.e. grimace scale, body condition scoring, body weights, etc.)
  • If analgesia or other drugs are given in the post-operative period,
    • Name of drug given
    • Dose (total mgs given), dosage (mg/kg), volume (mls), route of administration
  • Signature or initials of person conducting the post-operative monitoring and/or administering analgesia