Recordkeeping and Documentation
What to know
Documentation questions test whether records are contemporaneous, attributable, legible, and retained for the required period. Know what must be recorded: animal identification, procedures performed, anesthesia and analgesia, health observations, treatments, deviations from protocol, and training records. Records must allow reconstruction of what happened, when, and by whom.
Understand the difference between source data and derived summaries. Corrections must preserve the original entry (single line, initial, date, reason) rather than obliterate it. Protocol deviations must be documented and, where required, reported. Retention periods vary by rule and institution; know that the longer applicable requirement governs.
Traps
- Backdating or erasing entries instead of making attributable corrections.
- Recording a procedure without documenting anesthesia or analgesia.
- Assuming verbal instructions satisfy documentation requirements.
- Treating an electronic record as exempt from audit trails.
Rule of thumb
If it was not documented, it did not happen - write it when it happens, and correct it without destroying the original.
Worked example: A technician realizes a treatment was given but not logged until the next day. The correct action is to enter the record promptly, note the actual administration time, and flag the late entry - not to record the time the note was written.