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Medical Records for USDA-Covered Species

Related Information

Forms

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

USDA Medical Records used at the University of Wisconsin-Madison will have multiple sheets containing different pieces of information required by law:

 

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:

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:

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:

*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:

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:

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:*

*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:

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.

 

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