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  • Procedures for Veterinary Medical Records
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Last Updated 17 December 2010

  1. Purpose

    To describe the procedures for generating, maintaining, storing, and purging permanent medical records.
  2. Responsibility

    1. All Veterinary Personnel: Responsible for generating, maintaining, storing, and purging permanent medical records as outlined in this document.
      1. Veterinary technicians are also specifically responsible for:
        1. Reviewing submitted records from investigative personnel for completeness and incorporating them into the permanent medical record within 2 business days of receipt.
        2. Filing lab results into permanent medical records.
    2. Investigative Personnel: Responsible for submitting components of the permanent medical record to ULAM as described in the Guidelines on Medical Records for Investigative Personnel.
  3. Definitions

    1. Clinical Condition Score (CCS): A numeric representation of the severity of animal illness or injury.

      0

      No sufficient findings on physical exam. No action required; resolve.

      1

      Mild, focal lesion. Animal is bright, alert, and responsive with no other significant findings. Monitor until resolved. No treatment is required, but the animal may benefit from primary interventions (defined below).

      2

      Focal lesion that requires treatment and increased monitoring. Treatment may consist of primary interventions and/or topical (non-systemic) therapy. Animal is bright, alert, and responsive with no other significant findings.

      3

      Animal shows signs of systemic illness (e.g. quiet, alert, responsive, decreased body condition score, dehydration, etc.). Requires increased monitoring. May require systemic treatment/veterinary consult.

      4

      Animal is at protocol-specific or humane endpoint. Requires immediate action (e.g. veterinary consult, treatment, euthanasia, acute use, etc.).

      5

      Animal is moribund and requires immediate euthanasia unless other arrangements have been formalized through a ULAM Special Treatment or Procedure (SToP) form or the approved animal use protocol.


    2. Clinical Number: A number assigned to an animal or group of animals by the veterinary personnel. Each number includes the year the number was issued and the next available 5-digit number.
      1. Example: 09X23711 would represent clinical case number 23711 from the year 2009.
    3. Permanent Medical Record: A file identified by an animal's clinical number that contains all health, surgical, and/or procedural records generated for an animal. This may include:
      1. Animal Treatment Report (ATR): A form completed by animal husbandry personnel or investigative personnel requesting veterinary personnel examine the animal.
        1. For some animals (rodents) the entirety of the permanent medical record is captured in the ATR.
        2. Refer to the Animal Care Identification and Communication Procedures.
      2. Animal treatment check-off sheet: A full page form which lists an animal's treatments over time with areas for treatments to be checked off and initialed as they are completed. This is one method for documenting treatments.
      3. Health records: Written documentation of animal health including physical exam findings, illness, injury, treatments, veterinary procedures, vaccination records, interpretation of diagnostic tests, weight logs, weight logs, etc.
        1. This includes ATRs and entries on treatment and observation sheets.
      4. Surgical records. Refer to:
        1. Guidelines on the Performance of Surgery in Rodents
        2. Guidelines on the Performance of Surgery in Non-Rodent Mammals
        3. Anesthesia and Sedation Monitoring Guidelines
      5. Anesthesia or sedation monitoring forms. Refer to:
        1. Guidelines on the Performance of Surgery in Non-Rodent Mammals
        2. Anesthesia and Sedation Monitoring Guidelines
      6. Post-operative records. Refer to:
        1. Guidelines on the Performance of Surgery in Rodents
        2. Guidelines on the Performance of Surgery in Non-Rodent Mammals
      7. Diagnostic test results: e.g. CBC/chemistry, urinalysis, culture and sensitivity, serology, etc.
      8. Radiographs
      9. Master problem list: a list of an animal's health problems that serves as an index to its permanent medical record. It includes each problem, and the dates each was noted and resolved.
      10. Necropsy report: A report of gross and/or histologic post mortem findings.
      11. Food and water consumption chart (food chart): A full page form for recording the amount of food and water provided and consumed by an animal in a given day. This form is typically initiated and monitored by veterinary technicians for those animals that have a clinical concern for the over- or under- consumption of food and/or water. It may be initiated by other University personnel as well.
      12. Non-human primate alopecia score sheets. Refer to:
        1. Evaluation of Alopecia in Nonhuman Primates
      13. Veterinary recommendations: Documents drafted by the veterinary staff describing treatments or procedures not described on the animal use protocol meant to address the welfare of individual or groups of animals. Refer to:
        1. Procedures for Completion of Veterinary Recommendations
      14. Enrichment records: All records or logs pertaining to enrichment provision or exemption for select species. Refer to:
        1. NHP Enrichment and Husbandry Log
        2. Environmental Enrichment for Animals SOP
        3. OBSOLETE - Social Introduction of Laboratory Animal Species
      15. Exercise records: All exercise logs or exemptions from exercise for select species. Refer to:
        1. Dog Husbandry SOP
      16. Social housing records: All records pertaining to the introduction of new pairs or groups, regular observations of stable groups/pairs, and animals exempt from social housing. Refer to:
        1. Identifying Single Housed Animals SOP
        2. OBSOLETE - Social Introduction of Laboratory Animal Species
        3. Procedures for Nonhuman Primate Socialization
        4. Dog Husbandry SOP
      17. SToP form: Request for Special Treatment or Procedure. Refer to:
        1. Request for Special Treatment or Procedure (STOP) Form and Form Completion Instructions
      18. Records generated and/or submitted by investigative personnel including arrival papers and records of disposition of dogs and cats.
        1. Record of disposition: A record of the death, euthanasia, transfer, sale, adoption, or donation of an animal. Refer to:
          1. UM Disposition Records for Dogs and Cats Procedures
    4. Non USDA-Covered Species: A term that refers to animals whose care is NOT governed by the Animal Welfare Act. This includes rats of the genus Rattus and mice of the genus Mus bred for research, birds, fish, reptiles, and amphibians.
    5. Treatment and Observation Sheet: A full page form used for documenting information for inclusion in the permanent medical record.
    6. Treatment Card: A cage card-sized form for recording rodent treatments as they are completed. This is one option for documenting treatments provided by investigative personnel.
    7. USDA-Covered Species: A term that refers to animals whose care is governed by the Animal Welfare Act. USDA-covered species include all live or dead, warm blooded animals used in research except birds, rats of the genus Rattus and mice of the genus Mus bred for research. This also excludes "cold-blooded" animals such as fish, reptiles, and amphibians.
    8. Veterinary Personnel: All ULAM veterinary technicians, veterinary residents, and faculty veterinarians.
  4. Procedures

    1. Generating records and assigning clinical numbers:
      1. Non USDA-covered species: Create a record (complete an ATR if one has not already been generated) and assign a clinical number when animals are reported for a health concern.
        1. Assign a single clinical number and use a single ATR per cage/tank.
        2. Note which individual(s) in the cage/tank were reported for a health concern on the ATR.
      2. USDA-covered rodents (e.g. guinea pigs, cotton rats, degus, chinchillas, etc.): Create a record (complete an ATR if one has not already been generated) and assign a clinical number when animals are reported for a health concern.
      3. All other (non-rodent) USDA-covered species: Create a record and assign a clinical number upon arrival.
      4. Complete an ATR and assign a clinical number for animals submitted for necropsy without a clinical number.
      5. Veterinarians assign clinical number to individuals or groups of animals receiving care described in a veterinary recommendation. The log for veterinary recommendation clinical numbers is located on the network share drive located at \\maize.umhsnas.med.umich.edu\ULAM\ULAM_General-Veterinary\Veterinary-Recommendations\. Refer to:
        1. Procedures for Completion of Veterinary Recommendations
      6. The Rodent Health Surveillance Team assigns clinical numbers to rodent pathogen outbreak. Refer to:
        1. Procedures for Veterinary Outbreaks
      7. Assign clinical numbers by entering the Principal Investigator's name and the 3 letter species code alongside the next available clinical number by species or clinical area:
        1. 10,000-19,999 – Large animals
        2. 20,000-29,999 – Med Sci, ARF, Buhl
        3. 30,000-39,999 - MSRB
        4. 40,000-49,999 – Surveillance/ Veterinary Recommendations
        5. 50,000-59,999 - LSI
        6. 60,000-69,999 - NCRC
        7. 70,000-79,999 - BSRB
        8. 80,000-89,999 - CC
        9. 90,000-99,999- Brehm/Kellog
        10. A separate database is kept for all living nonhuman primates given clinical numbers since 1986. This is stored with the active primate records in the veterinary technicians' office.
        11. Write the clinical number on the animal's cage card, at the top of the ATR, and on each page of the permanent medical record.
    2. Maintaining records:
      1. Entries:
        1. Record all aspects of case management in the permanent medical record (on the ATR or a treatment and observation sheet). Entries must be sufficiently detailed such that the health history of the animal can be reconstructed. This includes information on:
          1. Presentation
            1. Species, strain, age, sex
            2. History
            3. Experimental use and manipulations
            4. Presenting complaint – include in clinical entries and the master problem list
          2. Exam findings
          3. Procedures and interpretations (e.g. radiographs, CBC/chemistry, urinalysis, etc.)
          4. Assessment and clinical condition score
          5. Diagnosis
          6. Plan
            1. Monitoring: define monitoring frequency or next planned recheck, include parameters for intervention.
            2. Treatments or other interventions (e.g. dietary support, nail trims, etc.)
              1. Write drug names in full, do not abbreviate.
              2. Include dose, route, and frequency.
              3. Include who is responsible for treatments (veterinary versus investigative personnel).
                1. Treatments for USDA-covered species performed by investigative personnel must be documented and submitted for incorporation into the permanent medical record.
              4. Enter treatments in the permanent medical record as they are completed.
              5. For animal being treated with analgesia "as needed," personnel MUST note that an animal is not painful/no longer needs analgesics BEFORE analgesics are discontinued.
            3. Communication with investigative personnel including permission to treat.
            4. Communication with other veterinary personnel members regarding case management.
          7. Progress: describe changes in animal condition and/or plan.
          8. Outcome (e.g. resolved, euthanized, submitted for necropsy, etc.).
            1. Enter the necropsy number in the permanent medical record for animals submitted for necropsy.
        2. All entries in the medical record must be signed or initialed and dated.
        3. All entries in the medical record must be signed or initialed and dated.
        4. Strikethrough (strikethrough) and initial entries that need to be corrected. The original entry must remain legible. Justify and define any corrections or changes.
        5. A list of accepted abbreviations can be found in Appendix A.
      2. Organization: Organize records such that the most recent paperwork is located on top with treatment and observation sheets on the right and diagnostic results and the master problem list on the left.
    3. Storing and submitting records:
      1. Active cases:
        1. Non USDA-covered species: Records are stored in file boxes or at the desk of the area veterinary technician unless alternate arrangements have been made and communicated with the veterinary personnel.
        2. USDA-covered species: records are stored in the filing cabinet(s) in or adjacent to the veterinary technicians' offices (2614B MSI, G04N NCRC, B018 BSRB, SRF office).
          1. Some or all paperwork pertinent to an active case can be temporarily maintained outside of these locations.
          2. Keep the pertinent papers together (as a paper-clipped packet) with the most recent papers on top.
            1. During the day, the packet may be kept in one of four places:
              1. in or adjacent to the animal room
              2. with the veterinary technician as they perform their daily duties
              3. on the veterinary technician's desk (or farm office)
              4. on the veterinary resident's desk
            2. On evenings and weekends, store the packet on the desk of the responsible veterinary technician (or farm office).
            3. The responsible veterinary resident or faculty member can access the record from the veterinary technician. The record must be returned to the veterinary technician (or farm) office and stored there overnight.
            4. Add the packet to the permanent medical record when the case is resolved.
        3. All species:
          1. Some components of the permanent medical record may be temporarily or permanently stored outside of the permanent medical record. These may include:
            1. Enrichment, exercise, or social housing records
            2. Veterinary recommendations
            3. SToP forms
            4. Radiographs
          2. These components are referenced in the permanent medical record and are linked by clinical numbers.
        4. See Appendix B for specific storage information.
      2. Inactive cases: The regulations for storing inactive records vary by species.
        1. Non USDA-covered species: records are maintained for 6 years from the date of generation.
          1. Store ATRs (and any associated lab results or treatment and observation sheets) in numerical order in filing boxes in room 2452 MS I (storage room).
        2. All USDA-covered species except nonhuman primates: records (including ATRs, test results, treatment and observation sheets, etc.) are maintained for a minimum of 6 years.
          1. Animals housed for 3 or more years: medical records are kept for 3 years after the date of death or euthanasia.
          2. Animals housed for less than 3 years: medical records are maintained 6 years after initial ATR generation.
          3. Records are stored in the filing cabinet(s) in or adjacent to the veterinary technicians' offices (2614B MSI, G04N NCRC, B018 BSRB, SRF office).
        3. Nonhuman primates: medical records are kept indefinitely and stored in MSI room 2452.
          1. Disposition of dogs and cats:
          2. Records of disposition must be generated for all dogs and cats and must include:
            1. USDA identification number
            2. Description of animal (species, breed, markings, sex, age)
            3. Date and manner of disposition (euthanasia, transfer, etc.)
          3. Records must be maintained for 3 years. Principal investigators leaving the University must forward their records to the UCUCA office for retention during the remainder of their 3-year UCUCA approval period.
    4. Purging and disposing of records:
      1. Records that fall outside of the 6-year maintenance period are removed from storage at the end of each calendar year.
      2. Put purged records in the locked bin in the ULAM Business office for confidential shredding.
  5. Related Documents

    1. Animal Care Identification and Communication Procedures
    2. Anesthesia and Sedation Monitoring Guidelines
    3. Dog Husbandry SOP
    4. Evaluation of Alopecia in Nonhuman Primates
    5. Guidelines on Medical Records for Investigative Personnel
    6. Guidelines on the Performance of Surgery in Non-Rodent Mammals
    7. Guidelines on the Performance of Surgery in Rodents
    8. Identifying Single Housed Animals SOP
    9. Request for Special Treatment or Procedure (STOP) Form and Form Completion Instructions
    10. Procedures for Completion of Veterinary Recommendations
    11. Procedures for Veterinary Outbreaks
    12. OBSOLETE - Social Introduction of Laboratory Animal Species
    13. Procedures for Nonhuman Primate Socialization
    14. UM Disposition Records for Dogs and Cats Procedures
  6. Appendices

    1. Appendix A: Accepted Veterinary Medical Shorthand and Acronyms
    2. Appendix B: Records Storage Reference Sheet
  7. Forms

    1. Non-rodent Mammal Anesthesia Monitoring Form
    2. Non-Rodent Mammal Post-Operative Record
    3. Primate Enrichment and Husbandry Log
    4. Request for Special Treatment or Procedure (STOP) Form and Form Completion Instructions
    5. Rodent Surgery Record and Cage Card Form
  8. References

    1. Animal Welfare Act and Regulations. Website at https://www.aphis.usda.gov/animal_welfare/downloads/Animal%20Care%20Blue%20Book%20-%202013%20-%20FINAL.pdf
    2. Field K, Bailey M, Foresman LL, et al. (ACLAM Medical Records Committee). Medical records for animals used in research, teaching, and testing: public statement from the American College of Laboratory Animal Medicine. ILAR J. 2007;48(1):37-41.
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