Effective clinical documentation is crucial in the veterinary field, particularly in outpatient emergency contexts. A well-structured template enhances clarity, ensuring that every relevant detail is captured accurately. The following guide provides a step-by-step process for documenting a case using a detailed template, focusing on a 5-year-old Labrador Retriever experiencing vomiting and lethargy.

Reason for Visit

The documentation begins with the reason for the visit, succinctly outlining the primary concerns. In this case, the reason is "Vomiting and lethargy." This section sets the stage for the subsequent history and examination.

History

The history section provides a detailed background of the patient's condition. For Max, this includes noting the duration of symptoms (24 hours), dietary habits (no food intake for 12 hours), and activity levels (less active than usual). A comprehensive history should also cover pre-existing conditions (none known), potential toxin exposure (none reported), vaccination status (up-to-date), and current medications (none mentioned).

Triage

Triage data captures the initial clinical assessment. Key metrics include heart rate (HR: 120 bpm), respiratory rate (RR: 30 breaths/min), temperature (Temp: 39.0°C), mucous membrane color (pink and moist), capillary refill time (Crt: <2 seconds), mentation (QAR), pain scale (2), hydration status (5% dehydrated), blood pressure (120/80/95), and oxygen saturation (Spo2: 98%). These parameters provide a quick snapshot of the patient's physiological state.

Examination

The examination is a detailed assessment of each bodily system. Max's body condition score is 6/9, indicating a healthy weight. Cardiovascular and respiratory systems show normal findings, while mild abdominal discomfort is noted in the gastrointestinal exam. The neurological, musculoskeletal, urinary, reproductive, integumentary, lymph nodes, and eye examinations reveal no significant findings (NSF).

Problem List

Identify and list the main clinical issues: vomiting, lethargy, and dehydration. This concise problem list helps prioritize diagnostic and treatment strategies.

Differential Diagnosis

Based on the symptoms, potential diagnoses include gastroenteritis, pancreatitis, and foreign body ingestion. This list guides further diagnostic testing and treatment decisions.

Diagnostics

Document any tests performed. In Max's case, no diagnostics were conducted at the initial stage, reflecting a decision to start with symptomatic treatment.

Assessment

Summarize the clinical findings and hypothesize potential causes. For Max, the assessment suggests gastroenteritis or pancreatitis, with dehydration noted as a significant concern requiring supportive care.

Treatment

Detail the treatment plan, including administered subcutaneous fluids (Lactated Ringer's Solution, 500ml), prescribed antiemetic (Cerenia, 24mg once daily for 3 days), and dietary recommendations (bland diet for 3 days).

Plan

Outline discharge instructions and follow-up care. Max's owner is advised to monitor for ongoing vomiting or lethargy and ensure fluid and dietary intake, with a follow-up check scheduled in 48 hours if symptoms persist.

Incorporating AI medical scribes like Notis AI Medical Scribe can revolutionize veterinary documentation. This technology automates the creation of structured clinical notes, such as SOAP notes, significantly reducing the time spent on administrative tasks.

Efficiency and Accuracy with Notis AI

Notis AI Medical Scribe uses advanced voice-to-text technology, allowing veterinarians to dictate notes directly into a familiar interface like WhatsApp. This system not only saves time—up to 2 hours per day—but also ensures high accuracy with a 99% transcription rate.

Seamless Integration and Comprehensive Features

With capabilities including multilingual support and structured SOAP note generation, Notis provides a seamless integration into existing workflows without the need for additional software. Its comprehensive features, such as document analysis and smart retrieval, enhance both the efficiency and quality of patient charting.

By leveraging AI medical scribes, veterinarians can focus more on patient care, improving outcomes and reducing burnout. This innovative approach to patient documentation represents a significant advancement in veterinary medicine, particularly in high-demand specialties like veterinary emergency care.