Medical Records for USDA-Covered Species
Forms
- 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
Contacts
With the exception of rodents, who can have group records, all USDA animals must have individual records. RARC Veterinarians will create these medical records and coordinate with labs if they want individual or group records.
People responsible for maintaining animal records
- Veterinarians and other veterinary staff
- Principal investigators
- Other designated employees such as facility managers and research staff
USDA Medical Records used at the University of Wisconsin-Madison will have multiple sheets containing different pieces of information required by law:
- blue cover sheet (required)
- white sheet (required)
- goldenrod sheet (study dependent)
- green sheet (study dependent)
- orange sheet (study dependent)
Labs will create their own procedural records (you may use the surgery/anesthesia forms in the Related Information box). At a minimum a copy of these procedural/anesthesia records must be in the record by the morning of the day after the procedure.
When making medical record entries:
- Sign or initial, and date each entry
- Don’t skip lines
- Print legibly
- Use ink
- Be consistent with current professional veterinary standards
- Sufficiently complete record to show that animals received adequate veterinary care
- Do not include unnecessary information
- Strike through mistakes with a single line. Initial and date correction
Anesthesia Record and Monitoring Requirements
When performing anesthesia on USDA covered species you may use a form combining the anesthesia and procedure (surgical or non-surgical) or use separate forms. The following information is required on these forms:
Basic Information:
- 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 drug name, dose, total mg given, 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*
Before beginning any procedure, check depth of anesthesia (e.g., palpebral response, jaw tone, toe or tail pinch). A surgical plane of anesthesia is required before beginning a surgery.
Monitor and document these parameters at least every five to 10 minutes during a procedure. Remember to follow these or additional parameters as outlined in your protocol:
- 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 and some procedures may require additional parameter monitoring. Contact an RARC veterinarian for further information.
Rodent Anesthesia Monitoring
Before beginning any procedure, check depth of anesthesia (e.g., toe or tail pinch). A surgical plane of anesthesia is required before beginning a surgery.
Monitor and document these parameters at least every five to 10 minutes during a procedure. Remember to follow these or additional parameters as outlined in your protocol:
- Respiration
- Observe chest wall movement
- Pulse, heart rate, direct or indirect blood pressure (cuff or Doppler)
- Body temperature
Other Possible Parameters:
Mucus membrane color -- checked at muzzle, feet, ears, or tongue
Pulse oximetry
End tidal carbon dioxide
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.
This information may be on the anesthesia form if using a combined document.
Records must include:
- 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
Post anesthesia monitoring requirements and documentation
While still unconscious or semiconscious, all anesthetized animals must be examined at least every five to 10 minutes. 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
- Heart and respiration rates
- Body temperature – until it is >99 F
- Condition of surgical site (if applicable)
- Time of extubation (if applicable)
*Some of these parameters are not feasible in some species. Contact an RARC veterinarian for further information.
Keep animals warm and dry after anesthesia/surgery.
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. Once sternal, the animal must be checked every 30 minutes until standing without support.
After anesthetic recovery, animals must 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 (when possible, analgesics should be given pre or intra-operatively)
- Name of drug given
- Dose, total mgs given, route, volume
- Signature or initials of person conducting the postoperative monitoring and/or administering analgesia
Medical Records Retention
At UW-Madison, RARC maintains animal medical records for three years after the death or disposition of the animal.
Labs can only discard records with RARC approval.