Excluding agricultural animals utilized and housed at research and education centers.
Scope and Application
Medical records for animals used in research and teaching are a core component of adequate veterinary care. A medical record entry should be initiated for all survival and terminal procedures*. Information within the record must be recorded so that experimental manipulations, care, and course of treatment can be reconstructed, if necessary.
All entries in the medical record should be dated, indicate the originator of the entry (initials or signature) and be legible to someone other than the writer. Investigators are responsible for maintaining records related to experimental manipulations and may elect to maintain separate research records. Research records must contain the items detailed below and be available for review by OLAC staff and for internal (IACUC) or external (USDA, OLAW, or AAALAC, International) oversight uses.
All animal health records (including research records not duplicated in the medical record) must be held for at least 1 year after the animal’s disposition or death or longer if required by other regulatory agencies.
*The Office of Laboratory Animal Care has available a pre-formatted surgery/procedure record that can be used for rodents, amphibians, and reptiles.
Components of a Medical Record
Where applicable, the record must contain
- Animal or group identification and the date of the procedure
- Descriptions of any illness, injury, distress, and/or behavioral abnormalities and the resolution of the noted problem
- Dates, details, and results (if appropriate) of all medically-related observations, examinations, tests, and other such procedures.
- Dates and other details of all treatment (and research interventions) including the name, dose, route, frequency, and duration of treatment with drugs or other medications and volume of substances collected. (A “check-off” system to record when treatment is given each day may be beneficial.)
- A description of the surgical procedure and identification of the surgeon(s)
- Ongoing findings during anesthetic monitoring
- Notation of any variation from normal and expected events during anesthetic and recovery periods, including the actions taken
- Assessment for pain and distress
- Actions taken to alleviate pain and distress, including non-pharmacologic interventions, and the response to those actions
- Documentation of euthanasia or other disposition
- Documentation of necropsy findings
American College of Laboratory Animal Medicine. 2004. Public Statement: Medical records for animals used in research, teaching, and testing. Available online [PDF].
Animal and Plant Health Inspection Service, US Department of Agriculture. 2000. Veterinary Care (Policy 3). In: Animal Care Resource Guide. Washington DC: USDA. Available online [PDF]
Authored: September 24, 2010
Dr. William Hill
Approved: October 1, 2010
Patricia N. Coan, DVM, Ph.D.