Medical Records for USDA-Covered Species

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
  • Principal investigators
  • Other designated employees, such as facility managers and research staff

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Medical Records Retention

At UW-Madison, most animal medical records are archived by RARC staff. Contact RARC veterinarians with any questions.

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Medical Records

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

• • Animal Medical Record (cover sheet) (blue - required)
  • Animal Record (white - required)
  • Medical History Summary (yellow - if applicable)
  • Animal Vaccination Record (green - if applicable)
  • Animal Care Sheet (orange - if applicable)

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.

When making medical record entries: 

• • Sign or initial, and date each entry
  • Don’t skip lines
  • Print legibly
  • Use ink (blue or black)
  • Use professional language
  • Sufficiently complete the record to show that the animals received adequate veterinary care
  • Do not include unnecessary information
  • Strike through mistakes with a single line
    • Initial and date correction

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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, 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.

Required information on an Anesthesia Record:

• • 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), dosage (mg/kg), volume (mls), route of administration
  • 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)
  • Anesthesia start and stop times
  • Procedure start and stop times

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USDA-Covered 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 an anesthetic procedure.

Monitor and document these parameters at least every five to 10 minutes during a procedure. Follow the parameters listed below and additional parameters as outlined in your lab’s animal care and use protocol.

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

• • Heart rate (species and anesthetic drug-dependent)
  • Respiratory Rate (species and anesthetic drug-dependent)
  • Blood pressure
  • Mucus membrane color (can be checked at muzzle, feet, ears, or tongue)
  • O₂ saturation (recorded by pulse oximeter)- greater than 95%
  • End-tidal CO₂
  • Capillary refill time (species and anesthetic drug-dependent)
  • Body Temperature (species and anesthetic drug-dependent)
    • Animals may get cold under anesthesia; using an approved heat source during and after the procedure can help. If you mention use of a heating device in the protocol, you must use one.
  • Always keep a barrier between the animal and the heat source (example: a towel).

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USDA-Covered 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 an anesthetic procedure.

Monitor and document these parameters at least every five to 10 minutes during a procedure in which animals are under anesthesia for at least 10 minutes. Follow the parameters listed below and additional parameters as outlined in your lab’s animal care and use protocol.

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

• • Heart Rate
  • Respiratory Rate
  • Blood pressure
  • Body temperature
    • Animals may get cold under anesthesia; using an approved heat source during and after the procedure can help. If you mention use of a heating device in the protocol, you must use one.
    • Always keep a barrier between the animal and the heat source (example: a towel).

Other Possible Parameters:

• • Mucus membrane color (checked at muzzle, feet, ears, vulva, or tongue)
  • O₂saturation (recorded by pulse oximeter)
  • End-tidal CO₂

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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.

Records must include:

• • Date surgery is performed
  • Animal use protocol number
  • Animal or group identification
  • Species
  • 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 (if applicable)
    • Type of implant (if applicable)
    • Closure technique

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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.

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
  • Heart rate
  • Respiration rate
  • Body temperature – monitor until it is >99 F
    • Animals may get cold under anesthesia; using an approved heat source after 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 recovery cage will aid in optimal recovery. Place heat source under half of the recovery cage, providing a heated and unheated area to allow 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 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 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