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IG038: Medical Record Guidelines for USDA Covered Non-Rodent Species and Agricultural Animals used in Research and Teaching

IACUC Guideline Number: IG038, Approved By: IACUC, Approval Date: 2/12/2026, Version: 1

PURPOSE: This guideline outlines the standards for providing adequate veterinary care and maintaining appropriate medical records. According to The Guide for the Care and Use of Laboratory Animals, the Guide for the Care and Use of Agricultural Animals in Agricultural Research and Teaching, and the Animal Welfare Act and Regulations, medical records are a critical component of an effective animal care program. These records facilitate communication among veterinarians, research personnel, and all staff involved in the care of animals. This guideline specifically applies to records maintained for USDA regulated species, agricultural animals, and other non-rodent species.

DEFINITIONS:

USDA Covered Non-rodent Species: include rabbit, ferret, dog, cat, swine, sheep, cow, etc. and used specifically for biomedical research. 

Agricultural Species: Warm blooded vertebrate species intended for research, teaching or testing related to food/fiber production, breeding and management efficiency. 

Medical Records: Animal records include health, anesthesia, and surgery records. Records may be maintained at the cage level, on paper within a binder, or available electronically. 

Medical Records

Medical record entries are to be current, accurate, and complete. Records must be readily available, maintained with the animal and/or in a location that is readily accessible for veterinary staff.  Medical records may be kept at the cage level, electronically, or on paper.

At a minimum, medical records are to include the following information:

  • Animal identification, and general information, including species, source, date of birth, breed/strain, color/markings, gender, birth date
  • IACUC Protocol number
  • Procedures, treatments, and monitoring provided (these would include protocol required monitoring such as weight, body condition score, activity level, etc.)
  • Disposition (e.g., euthanized, transferred to another PI, adopted)
  • Method of euthanasia
  • Emergency contact information

Agricultural Species Records: For all animals maintained at the livestock teaching and research centers, farm staff must be notified of all medications, (antimicrobials, anesthetics, analgesia, etc.) given so appropriate withholding times can be recorded in the farm records.

Surgery Records

Records provide a complete description of the surgical procedure. The record includes the following:

  • Date of surgery
  • Animal protocol number
  • Animal identification
  • Species
  • Surgeon and contact information
  • Name of surgical procedure

Anesthesia Record

All anesthetized animals must be monitored; observations are to be documented every 5 minutes.  Parameters to include in assessment pre- and post-anesthesia may include:

  • Name of surgical procedure and date and time procedure performed
  • Name of people doing the procedure (surgeons, anesthetists, assistants, etc.)
  • Name, dose, route, and time of administration of all substances given
  • Physiological parameters including heart rate, respiratory rate, blood pressure, oxygen saturation, etc.
    • Note the initial values of parameters once a surgical plane of anesthesia has been reached
    • Document any significant changes in those parameters during surgery/anesthesia
  • Animal’s behavior, depth of anesthesia, positioning (lateral/sternal recumbency, etc.)
  • Document time and quality of recovery from surgery [NOTE: not necessary for nonsurvival procedures]
    • Ambulation and time of return to normal movement
  • Date sutures/staples removed

Post-Operative Records

Post-operative observations and treatments must be recorded and initialed on each date performed. For minor procedures, the animal should be observed at a minimum of 24 hours after the procedure. Depending on the intensity of the procedure, at a minimum, there must be daily entries as to the animal’s condition for 5 days following the procedure, or as outlined in the appropriate protocol. Please ensure that all daily entries are legible. 

Each page of surgical records should be initialed. Surgical/anesthesia records or copies must be accessible for review at all times. Record retention: Retention of all surgical records is the responsibility of the Investigator. In general, regulatory agencies require medical records and records of disposition to be kept for 3 years. However, some funding agencies and publishers may require a longer period of record retention. Check with your agencies and editors regarding their requirements.

USDA-APHIS-AC Policy #3: Veterinary Care, July 17, 2007.

  1. National Research Council, Institute of Laboratory Animal Resources. The Guide for the Care and Use of Laboratory Animals. National Academy Press, Washington, DC 2010.
  2. Field K et al. 2007. Medical Records for animals used in research, teaching and testing: public statement from the American College of Laboratory Animal Medicine. ILAR J 48(1): 37-41.
  3. Guide for the Care and Use of Agricultural Animals in Research and Teaching.  Fourth edition.