Records for Non-USDA Species Medical Care
- Anesthesia and Surgery Record
- Anesthesia, Surgery, Post-Op (rodent only: information for an anesthesia record, surgery record, and post-anesthesia monitoring can often be combined into a single document for rodents)
- Anesthesia Record
- Surgery Record
- Post-Op Log Continuation
You may maintain animal records in three different formats:
- Cage cards (for animals with simple medical records)
Note: at a minimum, cage cards must conform to policy UW-4104 , Cage Labeling Requirements
These records can be kept in the vivarium or the lab
Records must be readily available and accessible when veterinary staff or inspection personnel request to see them.
When making an entry into a medical record:
- Sign or initial and date each entry
- Print legibly
- Use ink
- Strike through mistakes with a single line. Initial and date the correction
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) may have a colony record instead of an individual record for each animal.
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 and monitoring afterwards
- Remember to keep track of adverse outcomes such as those that result in illness, injury, or behavioral abnormalities
- Procedure description should include date and results
- Treatments plans, including:
- Diagnosis (if any)
- Type, frequency, and duration of treatment
- Results of routine health monitoring procedures (species-appropriate) such as:
- Weight or body condition score
- Activity level
- Appearance of animal
- Tumor measurements
Anesthesia records requirements
When performing anesthesia for non-surgical or surgical procedures, you must fill out the anesthesia monitoring record and add it the animal/colony records. For rodent surgeries, most labs will use a combined anesthesia/surgery record.
Include the following in your anesthesia records:
- 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
- State the surgical approach
- Describe the actual procedure
- Type of material used to close incision
- Type of implant (if applicable)
- 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
Rodent Anesthesia Monitoring
- Before beginning any procedure, check the depth of anesthesia (e.g., toe or tail pinch).
- During the procedure, at a minimum, you must monitor for respirations by observing the chest wall for movement.
Other possible parameters to monitor during surgery:
- Pulse, heart rate, direct or indirect blood pressure (cuff or Doppler)
- Body temperature
- Mucus membrane color. Can be checked at muzzle, feet, ears, or tongue
- Pulse oximetry
- End tidal carbon dioxide
After an anesthetic event, monitor the animal until fully recovered, i.e., until the animal can normally ambulate around the cage.
Note: Animals get cold under anesthesia; using a heating pad/lamp* during surgery and/or after surgery can help recovery. Remember that if you mention use of a heating device in the protocol you must use one.
* Always keep a barrier between the animal and the heating pad. This may be a towel or the cage. Provide a heated area and unheated area in the recovery cage. Only use heat lamps with bulbs designed for animal heat support.
Medical Records Retention
At UW-Madison, we maintain animal medical records for three years after the death or disposition of the animal.