Accurate and detailed clinical documentation is vital in veterinary practice, particularly in emergency settings. In this guide, we will break down how to write and format inpatient veterinary notes effectively using a comprehensive template. This step-by-step tutorial will focus on veterinary emergency documentation, ensuring clarity and thoroughness in patient records.

Using a structured approach to document patient information not only enhances communication among veterinary staff but also ensures a high standard of care. Below, we explore each section of the template with practical examples:

Reason for Visit

This section clearly states the primary concerns for the veterinary visit. For example, "Vomiting and lethargy" succinctly summarizes the patient's presenting issues.

History

Document the patient’s background and recent history. Include details such as the duration of symptoms, any changes in behavior, and relevant medical history. For instance:

• The patient, a 5-year-old Labrador Retriever named Max, presented with acute vomiting and lethargy for the past 24 hours.

• Owner reports that Max has been less active and has not eaten since yesterday.

• Pre-existing conditions: No known pre-existing conditions

• Access to toxins: No known access to any toxins

• Current vaccination status: Up to date

• Current medications: Nil mentioned

Triage

Record vital signs and initial assessments. This includes heart rate, respiratory rate, temperature, and other critical metrics:

• HR: 120 bpm

• RR: 30 breaths/min

• Temp: 39.0°C

• Mm: Pink and moist

• Crt: <2 seconds

• Mentation: QAR

• Pain Scale (0-4): 2

• Hydration status (%): 5% dehydrated

• Blood pressure: 120/80/95

• Spo2: 98%

Examination

Provide a detailed examination report covering various systems such as cardiovascular, respiratory, and gastrointestinal. Example:

• Cardiovascular: Cardiac auscultation normal, normal rhythm

• Respiratory: Thoracic auscultation clear sounds bilaterally

• Gastrointestinal: Mild discomfort on palpation

Problem List and Differential Diagnosis

Identify and list the problems based on the examination findings followed by potential diagnoses:

• Problems: Vomiting, Lethargy, Dehydration

• Differential Diagnosis: Gastroenteritis, pancreatitis, foreign body ingestion

Assessment

Summarize the findings and provide a preliminary assessment. Example:

Max is a 5-year-old Labrador Retriever presenting with acute vomiting and lethargy. The primary concerns are dehydration and potential gastrointestinal upset.

Treatment and Plan

Outline the treatment provided and the plan for follow-up. Ensure clear instructions for the pet owner:

• Treatment: Administered subcutaneous fluids (Lactated Ringer's Solution) 500ml, Prescribed antiemetic (Cerenia) 24mg once daily

• Plan: Monitor for any further vomiting or lethargy. Recheck in 48 hours if symptoms persist or worsen.

AI medical scribes, like Notis AI Medical Scribe, offer a transformative solution to veterinary documentation. By automating the transcription and structuring of clinical notes, these tools significantly reduce the administrative burden on veterinarians, allowing more time for patient care.

Notis utilizes voice-to-text technology to convert patient interactions into structured SOAP notes with remarkable accuracy. Here are some key advantages:

Time Efficiency: By reducing documentation time by up to 80%, veterinarians can save approximately 2 hours each day, enhancing productivity and reducing burnout.

Ease of Use: Integrated with WhatsApp, Notis operates within a familiar interface, eliminating the need for additional software and facilitating a seamless transition.

High Accuracy: With a transcription accuracy of 99%, Notis ensures reliable and precise patient documentation.

In conclusion, mastering the art of veterinary inpatient documentation improves patient outcomes and communication. Leveraging AI solutions like Notis can further streamline this process, providing veterinarians with the tools needed to focus more on patient care and less on paperwork.