Required Health/Medical Record Keeping for Research and Teaching Animals
This standard describes Regulatory guidelines and standards of adequate veterinary care that impose certain requirements for health/medical records (Animal Welfare Act regulations; Guide for the Care and Use of Laboratory Animals; Guide for the Care and Use of Agricultural Animals in Agricultural Research and Teaching). All research and teaching animals at NC State must have veterinary care documented according to the USDA Animal Welfare Act.
All persons involved with the care and/or use of animals in research and/or teaching at the University including, but not limited to Principal Investigators, researchers, Animal Handlers, and students.
Communication to Attending Veterinarian
Each NC State animal resource unit must develop and maintain, in consultation with the University Attending Veterinarian/Primary Site Veterinarian, a system for medical record keeping. Format for medical records is flexible, as long as required elements are documented and clear (NCSU REG 10.10.10).
Documentation Requirements
Animal Identification
Means of animal identification include room, rack, pen, stall, and cage cards with written, bar-coded, or radio frequency identification (RFID) information. Identification cards should include the source of the animal, the strain or stock, sex, names and contact information for the responsible investigator(s), pertinent dates (e.g., arrival date, birth date, etc.), and protocol number.
Health Records
Health Records are meant to convey necessary information to all people involved in an animal’s care. Every facility is expected to have a system of health records sufficiently comprehensive to demonstrate the delivery of adequate health care. For all facilities, health records must be current, legible, and include, at a minimum, the following information:
- Identity of the animal – Identity of animal interpreted to mean positive individual identification, specific location of an isolated animal, or appropriate identification of herds, flocks, etc.
- 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, and other such procedures.
- Dates and other details of all 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 is recommended.
- 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 University Attending Veterinarian, or designee. In addition, it must include the veterinarian’s recommendation concerning activity level or restrictions of the animal.
- In the event that an approved SOP exists for prescribed treatment of common health conditions, the documentation requirements for the medical record still apply.
- Animal Care Tech Note: Daily Observation
Procedure Examples
Examples of procedures which should be adequately documented in health records include, but are not limited to:
- Physical examinations
- Vaccinations
- Fecal examinations
- Radiographs
- Surgeries (date, type of surgery, post operative monitoring)
- Invasive procedures
- Euthanasia/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 UAV or designee (e.g., on cage cards for rodents).
Record Retention
NC State University follows the UNC General Records Retention and Disposition Schedule, retention guidelines to manage the institution’s public records according to Policy 1.25.12.
Animal Care Records and Animal Research Records (Sections 6.1 and 6.2). Records documenting the use of animals for research. Includes manifests, disposition logs, reports, correspondence, and other related records. Destroy 3 years after final disposition of animals.
An animal’s health (care) records must be held for at least 3 years after its 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.(Note: Some records may need to be held longer to comply with other applicable laws or policies, i.e., destroy records of employee reports of misuse of animal subjects when all administrative and legal issues are resolved.)
References
- Animal Welfare Act regulations
- Guide for the Care and Use of Laboratory Animals
- Guide for the Care and Use of Agricultural Animals in Agricultural Research and Teaching
- UNC General Records Retention and Disposition Schedule
Updated December 2024