This resource has been fully reviewed and updatedA member of The Open Sanctuary Project’s staff has given this resource a full review and provided updates where necessary. by a member of The Open Sanctuary Project’s staff as of April 6, 2023. It was originally published on December 20, 2018.
Responsible operation of an animal sanctuary means providing the best care possible for your residents. One of the most effective tools in resident care is often overlooked: regular health documentation for every resident. Record keeping is essential in all aspects of a resident’s life at your sanctuary, but keeping a record of their health status is arguably the most critical. Neglecting to document information pertaining to the health of your residents could have serious implications for the individual, other residents at your sanctuary, and potentially your organization as a whole.
Each resident in your care should have their own collection of records, including records pertaining to their health such as intake evaluation records, health checkThe Open Sanctuary Project uses the term "health check" to describe health evaluations performed by caregivers who are not licensed veterinarians. While regular health checks are an important part of animal care, they are not meant to be a replacement for a physical exam performed by a licensed veterinarian. forms, veterinary exam notes, diagnostic reports, and treatment records. You can read more about creating, maintaining, and organizing permanent records for your residents here. Record keeping takes time and energy, two things that may already be in short supply for animal caregivers. If you look at record keeping as a formality unrelated to direct care, it can be easy for it to fall further and further down your to-do list. However, when you realize the ways in which thorough and accurate record keeping can help you provide your residents with the best care possible, you are more likely to properly prioritize it. In this resource we’ll discuss some of the ways in which health-related record keeping benefits your residents and your organization.
Documenting Each Resident’s Health History Benefits The Individual
Maintaining accurate and detailed records pertaining to your residents’ health can help you provide even better care to them!
Establish A Baseline For Each Individual
Keeping a record of their intake evaluation and all health checks, veterinary visits, and diagnostic reports allows you to easily look back at past findings to establish a baseline of their health that may be difficult to discern without these records. This allows you to compare current findings to past findings to determine if there has been a change or not.
Track Health Trends
Documentation can also help caregivers recognize the progression of a health challenge and the date specific signs first appeared. For example, a look back at a goat resident’s record might alert you to the fact that they tend to be stiff and sore following routine hoof trimming. By bringing this information to your veterinarian, you can discuss ways in which to keep the individual more comfortable for hoof trimming going forward, perhaps by administering an NSAID treatment in the days leading up to hoof trimming going forward.
Know How They Responded To Past Treatments
Recording the status of a treatment, both in terms of what was provided and how the individual responded to the treatment, allows you to look back at this information when making future treatment decisions. It’s important to point out that just because something did or did not work in the past does not always mean that will be the case (just because a particular antibiotic worked the last time Sammy was sneezing does not mean it will work this time, nor does it mean that their current illness is caused by the same pathogen as a previous illness), but it is still helpful to know the outcome of past treatments. In particular, if someone had an adverse reaction to a particular treatment, you would want to keep this in mind if this treatment is recommended again in the future. Having detailed information about what happened can help you and your veterinarian make the best decision possible going forward. This might mean avoiding the medication entirely, adjusting the dose or administration route, or using it in conjunction with another treatment to manage side effects.
Connect The Dots
If a resident tested positive for a certain disease at intake but did not show clinical signs of the illness until many years later, a look back at their record might help you see their current signs of concern in a whole new light. Similarly, a look through a resident’s record might allow you to recognize that this seemingly new issue they are dealing with could very well be a past issue resurfacing. By looking at the current situation while keeping their health history in mind, you may be more likely to catch and respond to early signs of an issue where you would have otherwise waited to see how things progressed.
Get Newcomers Up To Speed Quickly
If your sanctuary hires a new primary caregiver, or you decide to start working with a new veterinarian, regular health documentation can help them accurately and speedily get to know each of your residents, what makes them unique, and what their health challenges may be. Lacking this information could mean wasted time and resources, potentially missing out on important care needs that mustn’t be neglected for an individual, or missing a critical window of opportunity for early intervention in a health crisis.
Documenting Each Individual Resident’s Health Benefits All Of Your Residents
When you maintain detailed and organized records for each resident, you can use this individual data to help make better decisions for your resident populations as a whole.
Create Effective Living Arrangements
Documentation of resident health can help you determine who could safely and appropriately live with one another, especially if you need to split up residents. For instance, to prevent disease spread, you may decide to house CL-positive sheep residents separately from your other sheep residents.
Know What’s Around
Some diseases that can affect residents, such Johne’s disease, can survive in the environment for quite a long time and potentially infect other residents long after the first case pops up. If you have a record of an individual suffering from or passing away due to a specific communicable illness, you’ll be able to take steps to protect other residents. You’ll also be better prepared for it in case it affects other residents, with the knowledge of what early warning signs could look like. You can then provide early intervention if a different resident appears to become afflicted as well, using the recorded knowledge gained from the previous time it showed up on sanctuary grounds. This documentation is especially useful if one of your residents suffered from a difficult to diagnose disease in the past; you can review old data to look for patterns and potential solutions rather than losing time starting from square one.
Along these same lines, by keeping track of diagnostic reports and treatment efficacy, you’ll get an idea if and to what extent drug resistant pathogens are an issue. For example, through diagnostic testing of other individuals, you may realize that you are dealing with barber pole worms that are showing resistance to all classes of anthelmintics. You and your veterinarian can then work together to come up with screening, prevention, and treatment protocols that all your sheep, goat, llama, and alpaca residents will benefit from.
See Wider Patterns
Reviewing individual health records can help you track down problems that could affect an entire population at your sanctuary. For instance, it’s quite common for some species to develop vitamin or mineral deficiencies, either from nutritionally-inadequate forages or some environmental factor that inhibits vitamin absorption. Depending on the vitamin or mineral of concern, knowing deficiency is a concern may result in diet changes for an entire species of residents, the implementation of testing protocols, or sanctuary-wide supplementation per your veterinarian’s instructions. In other instances, it may just be that you and your team now know that this is a potential issue and are better equipped to recognize early signs of deficiencies going forward.
Benefits Of Health-Related Documentation For Your Organization
Maintaining thorough health records also has benefits for your organization as a whole!
Create More Effective Biosecurity Protocols
When you keep regular health records of individuals, you have a more detailed picture of what biosecurity challenges may need to be managed at your sanctuary. If a human (especially a young visitor) were to contract a zoonotic disease from one of your residents, there could be major implications for sanctuary residents and your organization as a whole, particularly if a human becomes seriously ill. By keeping track of and reviewing individual resident health patterns, you can determine how to best protect other residents and humans moving forward.
Be Able To Explain A Resident’s Current Condition
Because sanctuary residents sometimes come from settings where (at best) they have not received the individualized care they require and (at worst) have been victims of abuse or neglect, they may arrive at your sanctuary in very poor health. Should someone equate this to mean that your sanctuary does not properly care for its residents, thorough intake documentation can provide proof in legal actions that you are truly doing right by your residents, going above and beyond to give them a good life (intake records of a neglected animal should include documenting their body condition score and physical condition on arrival, ideally via veterinary assessment, and photo documentation of their condition upon intake and recovery since arrival). Neglecting to have this kind of documentation can make it much more difficult to provide evidence of your organization’s high standards of care.
Gain The Trust Of Veterinarians
Along these same lines, proper documentation allows you to demonstrate not only that you provide excellent care, but also that you understand the importance of record keeping. Being able to demonstrate that you and your team knows exactly who each resident is, have thorough records of their health and vaccination history, and that you closely observe them each day can go a long way in earning a reputation with veterinarians in your area that you provide excellent care and can be trusted. A veterinarian may be more likely to prescribe certain medications or pursue certain treatment options if they understand the level of care you provide and the care you take to document important health information. They may also feel more comfortable advocating for your organization or one of your residents during a disease outbreak or other situation that could pose a challenge for your sanctuary.
Record keeping is more than a formality – it’s an integral aspect of care. If you aren’t already, be sure to prioritize health-related record keeping today!
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