Documentation

Each workplace from early childhood to construction have policies and procedures. Animal care is no different. Policies and procedures are carefully developed documents that have been written in accordance with regulations specific to the industry. There are policies and procedures in place for virtually any type of situation from privacy and confidentiality to communication. It is important you familarise yourself with the workplace’s policies and procedures they have in place. When you are first employed, it is likely you will receive a staff handout book during your induction and taken through the workplace policies and procedures. These documents will be there for you to refer to at any time when you need additional clarification.

Depending on your animal care service, there will be various policies and procedures that you may need to familiarise yourself with prior to commencing work and making sure you are aware of any changes or updates that may occur internally (review cycle) and externally (updates to laws and regulations).

Below is a list of policies and procedures you may encounter in your role working with animals over various animal care settings.

 1. Animal Admission and Intake Policy

• Procedure for New Admissions: Steps for admitting new animals, including health assessments and documentation requirements.
• Quarantine Procedures: Guidelines for isolating new or sick animals to prevent the spread of disease.

2. Animal Health and Medical Care Policy

• Vaccination and Preventive Care: Requirements for routine vaccinations, deworming, and other preventive care measures.
• Medication Administration: Procedures for prescribing, storing, and administering medications to animals.

3. Animal Behavior and Handling Policy

• Handling Aggressive Animals: Guidelines for safely handling animals that display aggressive or fearful behavior.
• Behavioral Assessment Procedures: Steps for evaluating animal behavior and determining suitability for adoption or further training.
• Training and Enrichment Programs: Procedures for implementing behavioral training and enrichment activities.

4. Animal Welfare and Ethics Policy

• Humane Treatment Standards: Guidelines to ensure all animals are treated humanely, with respect and care.
• Euthanasia Policy: Criteria and procedures for humane euthanasia, including consent and documentation requirements.
• Animal Rights and Protection: Commitment to adhering to laws and regulations regarding animal welfare and protection.

5. Client Interaction and Communication Policy

• Client Confidentiality: Guidelines for maintaining the privacy of client information and animal medical records.
• Appointment Scheduling Procedures: Steps for booking, rescheduling, and managing client appointments.
• Customer Service Standards: Expectations for interacting with clients, including handling complaints and providing information.

6. Facility and Equipment Maintenance Policy

• Cleaning and Sanitation Procedures: Daily, weekly, and monthly cleaning schedules for cages, kennels, and common areas.
• Equipment Maintenance and Safety: Guidelines for the regular inspection, cleaning, and maintenance of medical and care equipment.
• Waste Disposal Protocols: Procedures for the proper disposal of biological and hazardous waste.

7. Staff Training and Development Policy

• Onboarding and Training: Procedures for training new staff on clinic policies, animal care, and safety protocols.
• Continuing Education: Requirements for ongoing staff education and training to keep skills and knowledge up to date.
• Performance Review Process: Guidelines for regular staff evaluations and feedback sessions.

8. Safety and Emergency Preparedness Policy

• Fire and Evacuation Procedures: Steps for safely evacuating animals and staff in case of fire or other emergencies.
• First Aid Protocols: Procedures for administering first aid to animals and staff in case of injury.
• Infectious Disease Control: Guidelines for managing outbreaks of contagious diseases within the clinic.

9. Record Keeping and Documentation Policy

• Medical Records Management: Procedures for creating, maintaining, and archiving animal medical records.
• Inventory Control Procedures: Steps for tracking and managing clinic inventory, including medications, food, and supplies.
• Incident Reporting: Guidelines for documenting and reporting any accidents, injuries, or unusual incidents.

10. Financial Management and Billing Policy

• Billing and Payment Procedures: Guidelines for invoicing clients, accepting payments, and managing outstanding accounts.
• Financial Record Keeping: Procedures for maintaining accurate financial records and compliance with tax regulations.
• Donation and Fundraising Policy: Guidelines for managing and documenting donations and fundraising activities.

11. Volunteer and Internship Program Policy

• Volunteer Onboarding: Procedures for recruiting, training, and managing volunteers at the clinic.
• Internship Program Guidelines: Expectations and requirements for interns, including duties and supervision.
• Volunteer Safety and Conduct: Guidelines for ensuring the safety and proper conduct of volunteers while working with animals.

12. Adoption and Rehoming Policy

• Adoption Screening Procedures: Steps for evaluating potential adopters to ensure suitable homes for animals.
• Adoption Contracts and Agreements: Legal agreements outlining the terms of adoption, including return policies.
• Post-Adoption Follow-Up: Guidelines for follow-up communications with adopters to ensure the well-being of rehomed animals.

Record keeping is a form of written communication, specifically the maintenance of information that will likely be referred to at a later date.

In an animal care environment, you may be responsible for maintaining workplace records such as:

• client records
• treatment and medication notes/logs
• animal identification records
• dietary information
• training/socialisation/exercise details
• stock control
• financial records
• hygiene processes, just to name a few.

The more experience you obtain, the more familiar you will become with these workplace records and how they are used and filed. Records are important documents that often need to be kept for several years.

Best Practice for Record-Keeping

Effective record-keeping is crucial in the animal care industry to ensure high standards of care, legal compliance, and efficient facility management. By adhering to best practices and maintaining thorough documentation, animal care facilities can provide the best possible outcomes for the animals in their care.

• Consistency: Ensure that all records are updated regularly and consistently by the staff responsible for specific tasks.
• Accuracy: Double-check entries for accuracy, especially when recording medical treatments, medications, and incident reports.
• Confidentiality: Maintain the confidentiality of client information and sensitive animal health data, only sharing it with authorized personnel.
• Organization: Use a standardized system for organizing records, whether paper-based or digital, to facilitate easy retrieval and review.
• Training: Provide regular training to staff on proper record-keeping practices, emphasizing the importance of thorough and accurate documentation.
• Backups: Ensure that all digital records are regularly backed up to prevent data loss, and that paper records are stored securely.

Digital VS Paper Record

• Digital
  • Advantages
    • easy to update, search and share
    • reduces physical storage space
    • often includes built-in reminders or treatment.
  • Disadvantages:
    • requires reliable software and hardware
    • potential for data breaches if not properly secured.
• Paper
  • Advantages
    • no need for technology
    • can be easier for some staff to update on the go.
  • Disadvantages
    • requires significant physical storage space
    • harder to search and organize
    • at risk of damage or loss.

Types of Records you may encounter or required to help maintain/manage

Animal Health Records

• Medical History:
  • Detailed records of each animal's medical history, including vaccinations, surgeries, treatments, and any chronic conditions.
  • Documentation of any medical procedures performed, such as spaying/neutering, dental work, or wound treatment.
• Vaccination Records:
  • Records of all vaccinations administered, including dates, types of vaccines, and the next scheduled vaccinations.
• Medication Administration:
  • Logs of all medications given to an animal, including dosage, frequency, and the administering staff member's name.
• Health Monitoring Logs:
  • Daily or periodic logs track an animal's vital signs, weight, appetite, behaviour, and overall health status.

Intake and Adoption Records

• Intake Forms:
  • Documents that capture essential information when an animal is first brought into the facility, such as species, age, gender, and initial health assessment.
• Behavioural Assessments:
  • Records evaluate the animal's temperament, socialization, and any behavioural issues.
• Adoption Contracts:
  • Legal agreements outlining the terms and conditions of an adoption, including the adopter’s responsibilities and any follow-up requirements.

Daily Care Logs

• Feeding Records:
  • Documentation of feeding schedules, types of food provided, and any changes in diet.
• Exercise Logs:
  • Records of the animal's physical activities, including walks, playtime, and other forms of exercise.
• Cleaning and Maintenance Logs:
  • Logs documenting the cleaning of cages, kennels, and other living spaces, as well as any facility maintenance performed.

Incident and Safety Reports

• Incident/Injury Reports:
  • Detailed accounts of any accidents or injuries involving animals or staff, including the circumstances and actions taken.
• Behavioral Incident Reports:
  • Documentation of any significant behavioural incidents, such as aggression or escape attempts, and how they were managed.
• Lost/Found Animal Reports:
  • Records of animals that go missing or are found, including descriptions, identification details, and recovery actions

Compliance and Regulatory Documentation

• Licenses and Permits:
  • Documentation of the facility’s operating licenses and permits, and compliance with local, state, and federal regulations.
• Inspection Reports:
  • Records of health and safety inspections conducted by regulatory bodies, along with any required corrective actions.
• Quarantine Logs:
  • Documentation of animals placed in quarantine, including the reason for quarantine, duration, and health monitoring.

Financial and Inventory Logs

• Billing and Payment Records:
  • Documentation of services provided, fees charged, payments received, and any outstanding balances.
• Inventory Logs:
  • Records of supplies on hand, such as food, medications, and cleaning products, to ensure proper stock levels.
• Donation and Fundraising Records:
  • Documentation of donations received, including donor information, amounts, and how the donations were used.

Training and Staff Records

• Staff Training Logs:
  • Records of training sessions attended by staff, including dates, topics covered, and any certifications earned.
• Volunteer Records:
  • Documentation of volunteer activities, hours worked, and any training or orientations completed.

As you would probably imagine, there are specific record-keeping guidelines that need to be considered to ensure they remain confidential and legible.

The following are guidelines for record-keeping and should always be observed.

• Handwrite legibly if using paper-based documents and complete accurate data entry when using computers.
• Include your name and signature where applicable.
• Make sure your date and, if necessary, timestamp the record.
• Be mindful of your language, remember the records may be shown to members of the public someday, avoid abbreviations if you can, and never write any insulting comments.
• Be objective and focus on facts, not speculation.
• Do not erase information that has previously been recorded; if an amendment is required, cross out the older entry with a single line (so that it can still be read by others if need be) and write the new information next to it. Initial and potentially date the change.
• Respect privacy. If personal details are provided, inform people if you need to share details with any third parties.
• Save / store records in a secure location such as a database with login/password requirements or a locked filing cabinet.