University Committee on Animal Care

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Policy on Animal Health Records

Health records are meant to convey necessary information to all people involved in an animal's care. Every Principal Investigator should have a system of health records sufficiently comprehensive to demonstrate the delivery of adequate health care. Health records should be current, legible, and include, at a minimum, the following information:

• Identity of the animal.
• Descriptions of any illness, injury, distress, and/or behavioral abnormalities and the resolution of any noted problem.
• Dates, details, and results (if appropriate) of all medically-related observations, examinations, tests, surgeries, and other procedures.
• Dates and other details of all research procedures and treatments, including the name, dose, route, frequency, and duration of treatment with drugs or other medications. ( A "check-off" system to record when treatment is given each day may be beneficial.)
• Treatment plans should include a diagnosis and prognosis, when appropriate. They must also detail the type, frequency, and duration of any treatment and the criteria and/or schedule for re-evaluation(s) by the attending veterinarian. In addition, it must include the attending veterinarian's recommendation concerning activity level or restrictions of the animal.

Examples of procedures which should be adequately documented in health records include, but are not limited to, vaccinations, fecal examinations, radiographs, surgeries, anesthesia/analgesia and necropsies. 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. However, individual treatment of an animal must be on an entry specific to that animal. As long as all required information is readily available, records may be kept in any format convenient to the Principal Investigator (e.g., on cage cards for rodents or lab manual).

Health records may be held by the investigators or the attending veterinarian or divided between both (if appropriately cross-referenced), however, it is the responsibility of the University Committee on Animal Care to ensure that all components of the records are readily available and that the record as a whole meets the requirements listed above.

The health records should be held for at least 3 years for dogs, cats, farm animals, and rabbits, and for at least 1 year for rodents and other vertebrate animals after disposition or death. When an animal is transferred to another party or location, a copy of the animal's health record must be transferred with the animal. The transferred record should contain the animal's individual medical history, information on any chronic or ongoing health problems, and information on the most current preventive medical procedures (for example, the most recent vaccinations and dewormings).

Approved by the ETSU University Committee on Animal Care: October 20, 2000