Purpose

The purpose of this policy is to provide guidance for the documentation of medical care for laboratory animals.

Policy

Veterinary medical records are required by the USDA Animal Welfare Act, and the Public Health Service Policy, the ILAR Guide for the Care and Use of Laboratory Animals, and the Guide for the Care and Use of Agricultural Animals in Agriculture Research and Teaching, as a component of the veterinary care program.

All animal records must be current, legible, sufficiently comprehensible to demonstrate the delivery of adequate veterinary care, consistent with professional standards, and available to the Attending Veterinarian (or delegate). Medical problems and procedures must be noted in the animal’s medical record along with observations, examinations and diagnostic test results, treatment plans, and resolution. Procedures such as radiographs, surgeries, and necropsy findings must also be kept as part of the animal’s medical record.  The USDA Policy #3 (attachment 1) provides guidance on what constitutes an adequate veterinary record and is the basis for this policy.

Procedure

1. The following elements are required to be in the medical record.

1. A unique identification number (animal identification number). In the case of rodent colonies, if it is not necessary to identify each individual animal; assign a unique identification number to each cage or colony.
2. Record the species of the animal.
3. Record the date of birth of the animal.
4. Record the breed or strain of the animal.
5. Record the gender of the animal.
6. Record the weight of the animal.
7. Record the date and initials of the person completing the record

2. If the procedure is a routine procedure or part of the preventative medicine process, which includes vaccinations, dewormings, castrations, tail dockings, annual physical exams, etc., it must be included in the medical record.
3. Routine husbandry and preventive medical procedures (e.g., vaccinations and dewormings) performed on a group of animals may be recorded on herd-health-type records.  The information must still include the procedure and a list of animal’s identification.
4. If a medical problem is being recorded, it must contain the following information.

1. Record the history, including any experimental manipulation, inoculations or infections, and the animal care and use protocol number.
2. Record the problems (signs of illness) or diagnosis.
3. Record conditions that can be observed but not quantified such as attitude or hydration status.
4. Record information that can be quantified such as temperature, pulse or respiration.
5. Record the treatment plan or follow-up plan.
6. Record the resolution of the case. 

The Veterinary Medical Record (attachment 2) must be kept in a place where it is easily accessible by the veterinary staff, preferably in the animal room, barn or kennel where that animal is housed. 

Health records must be maintained for three years following the death or disposition of the animal. 

Copies of the records must be transferred with the animal when the animal is transferred to a different investigator or facility.

Procedure: IACUC-35
Date: September 30, 2004
Enabled By: AWA
Supersedes: New