Medical Records

Client Information

Name of owner

Address (mailing and email)

All applicable phone numbers (home, cell, and work phone numbers) and fax numbers

Additional information if co-owned:

Other adult family members or responsible parties/authorized agents

Alternative emergency contact information

If applicable, referring person

Patient Information

Name of animal

Signalment: species, breed, age, sex, and spayed/neutered

Color and markings

Tattoo, microchip number, and identification (ID) number

Pertinent History

Presenting complaint

Last normal (last time patient was known to be normal)

Frequency of episodes

Client observations and/or concerns

Current medications

Allergies

Current diet

Transfusion history

Recent travel history

Previous History

Presenting complaint

Last normal (last time patient was known to be normal)

Frequency of episodes

Client observations and/or concerns

Current medications

Allergies

Current diet

Transfusion history

Recent travel history

Physical Examination

Initial physical examination findings

Progress notes and SOAP (subjective, objective, assessment, planning) notes

Master problem list

Working problem list

Diagnosis

Tentative diagnoses

Definitive diagnoses

Prognoses

Diagnostic Results

Laboratory reports

Reports and assessments of diagnostic procedures (endoscopy, radiography, ultrasonography, and special imaging)

Description of surgical and dental procedures, including duration of procedure and name of surgeon

Anesthetic record

Consultation reports with specialists or other referring veterinarians (dermatology, oncology, cardiology, ophthalmology, surgery, internal medicine, dentistry, and neurology)

Necropsy report

Therapeutic Plans

Changes in therapy

Medication administration and order record (MAOR)

Name of medication

Time

Date

Dosage and directions

Fluid rate

Route of administration

Frequency

Duration of treatment

Identification of individuals administering treatments

Cautionary Notes

Slaughter withdrawal and/or milk withholding dates (food animal)

Client communications

Signed consent forms

Client waivers or deferrals of recommendations

Client phone communication log

Discharge instructions

Financial records

Problem-Oriented Veterinary Medical Record

an organized approach to clinical veterinary care in that information in the medical record is grouped by problem, and each problem is addressed separately

Source-Oriented Veterinary Medical Record

patient information is organized by subject matter

Laboratory reports, for example, may be kept separate from progress notes, which are written in chronologic order. Clinical observations are entered as they become evident. In this way, the most recent information is located last and the oldest information is found first in a hard copy (paper) record and in many electronic systems, chronologic history is displayed with the most recent entries first.

Medication Administration/Order Record

ward treatment sheet; hospitalized patients are given treatments, diagnostic tests, and diet as requested by the attending veterinarian

Oxygenation

Altered Gas Diffusion

Altered Ventilation

Cardiac Insufficiency

Decreased Perfusion

Obstructed Airway

Risk of Aspiration

Priority 1

Oxygenation

Critical safety and/or severe pain

Acute Pain

Electrolyte Imbalance

Hyperthermia (Severe)

Hypothermia (Severe)

Postoperative Compliance

Preoperative Compliance

Priority 2

Critical safety and/or severe pain

Hydration

Hypervolemia

Hypovolemia

Priority 3

Hydration

Elimination

Altered Urinary Production

Bowel Incontinence

Constipation

Diarrhea

Inappropriate Elimination

Self-Care Deficit

Urinary Incontinence

Priority 4

Elimination

Nutrition

Altered Oral Health

Abnormal Eating Behavior

Ineffective Nursing

Overweight

Self-Care Deficit

Underweight

Vomiting and/or Diarrhea

Priority 5

Nutrition

Noncritical safety

Altered Mentation

Altered Sensory Perception

Noncompliant Owner

Hyperthermia

Hypothermia

Impaired Tissue Integrity

Owner Knowledge Deficit

Risk of Infection

Risk of Infection Transmission

Self-Inflicted Injury

Status Within Appropriate Limits

Priority 6

Noncritical safety

Chronic pain or mild-to-moderate acute pain

Acute Pain

Chronic Pain

Priority 7

Chronic pain or mild-to-moderate acute pain

Activity

Exercise Intolerance

Reduced Mobility

Sleep Disturbance

Priority 8

Activity

Utility

Aggression

Anxiety

Client Coping Deficit

Client Knowledge Deficit

Fear

Inappropriate Elimination

Reproductive Dysfunction

Priority 9

Utility