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Writing as a Veterinary Technician

This section is intended to provide veterinary technicians with guidelines for writing the patient care plan portion of the veterinary medical record. As there is no standardized format for writing a veterinary care plan, the following principles are only one example of how a care plan may be formulated. These principles have been adapted from materials developed by veterinary technology instructor/academic advisor Jamelyn Schoenbeck Walsh and veterinary instructional technologist Margaret Lump of Purdue University’s Veterinary Technology Program.  

Veterinary medical records must be complete, accurate, orderly, and legible and should give a description of what was done, when, by whom, why, how, and where. Because they are legal documents, certain conventions must be followed when recording information. Of concern are legal issues surrounding documentation.

A patient’s record is a compilation of all written information, reports, and communication regarding the patient’s care, and it should render a full understanding of the patient’s health status. To this end, a patient care plan should include, but is not limited to, the following parts:

• Patient signalment and client information
• History and presenting chief complaint
• Current health status and history
• Past, birth, and referral history
• Patient assessment
• Technician evaluation
• Interventions
• Rationale for interventions
• Continued patient reassessment
• Desired resolutions
• Progress notes
• Discharge planning

Each of the sections above contains guidelines on what information to include and how, as well as relevant examples of how a specific case might be documented.

A complete sample patient care plan will be available soon. Please note this PDF is a sample and should not be used as a template. For formatting questions, consult your instructor.

Patient Signalment, Client Information

Objectives

• To collect, classify, and record required patient information.
• To identify the relevance and interrelationship of the information as it relates to:
  • Diagnosis
  • Treatment
  • Nursing care
  • Patient progress

What to Include

Date and time of admittance: Establishes a starting point for intervention and monitoring

Signalment: Assists with proper identification of the patient, diagnosis, and predilections to traits and conditions as some conditions may be species, breed, gender, age, and color specific. Note: Most signalment information does not change over time. Exceptions to this include acquired markings, age, reproductive status, and means of identification.

Patient identification: Name, number, electronic ID

Species

Breed

Gender and reproductive status

Age: In years, months, weeks, or days depending on age of patient

Color: In order of predominance

Distinctive markings: Genetic and acquired (including tattoos, ear notches and cropping, scars, tail docking, etc.)

Client information, including:

• Client name
• Contact information: Patient address also provides geographical history of patient which may help in assessment. Include a second party emergency contact.
• Co-owner information: Important for treatment and euthanasia decisions
• Referring veterinarian if applicable

History, Presenting Chief Complaint

Objective

• To obtain a detailed chronological narrative of events from the client
• To record all actions, events and/or behaviors of the patient leading up to the current injury or illness.

What to Do

When obtaining information from a client, keep in mind the followign guidelines:

Direct the flow of conversation by requesting rather than suggesting answers. Ensure that you are not putting words into a client’s mouth or biasing the client’s answers.

• Ask open-ended questions
• Record the information in the client’s own words

Follow up with qualifying questions about the first problem before moving on to a new problem.  

After taking the history (1) use reflective listening and confirm information by paraphrasing important points, and (2) record information in patient record.

Things to Remember

Remember that the client and veterinary health care team will have similar but not identical concerns. 

• The client will be concerned with probability of recovery with/without treatment, complete vs. partial recovery, and nature and cost of treatment. 
• The veterinary health care team will be concerned with obtaining meaningful information about patient’s medical history to assist in the development of a definitive diagnosis and appropriate treatment plan.

Distinguish between client observations (facts) and interpretations of observations.

Determine if the information the client provides is first or second hand.

No information is better than the wrong information

Note: Collecting a patient history is both a science (asking the right questions), and an art (asking them in the right way).

What to Include  

Onset of the current problem
 

Anatomical location of the problem or body system affected

Character of the problem, including:

• Quality
  
  "The vomit contained whole food and watery fluid."
• Severity
  
  "Fido has violent retching followed by projectile vomiting."
• Onset
  
  "The vomiting started yesterday morning."
• Duration
  
  "Fido has been vomiting for about a week."
• Time of day
  
  "Fido vomits mostly in the morning."
• Frequency
  "Fido vomits multiple times a day."
• Triggers (influences related to the occurrence of the problem):
  • Setting
    "Fido vomits shortly after eating."
  • Factors that increase signs
    "Fido vomits when she rapidly eats a lot of food."
  • Factors that decrease signs
    "Fido doesn’t vomit when I feed her small amounts of food divided over several hours."
  • Associated problems
    "Fido also has diarrhea occasionally."
  • Progression
    "Fido seems to be vomiting more frequently."
  • Improvement
    "I haven’t noticed her vomiting today."
  
  

  *Parts adapted from Osborne, C.A. (2001). The Medical History: Are you asking questions right?. DVM, 32, 21.

Current Health Status, History

Objective

• To obtain further information about the current health status of patient from the client, which may or may not be related to the primary complaint.

What to Include

Tailor this information to the species of the patient.

• Other current medical or surgical conditions
• Allergies
• Diet/appetite/water intake:
  • Who feeds and waters?
  • Brand and type of food
  • Amount and frequency of food
  • Feeding patterns and procedures
  • Types of feeders/”waterers” (communal or individual)
  • Water source
  • Temperature and amount of water
  • Other water intake opportunities (puddles, ponds etc.)
  • Changes
• Bowel movements/urination: Amount, frequency, color, consistency, odor, changes
• Exercise: Amount, frequency, when, type, changes
• Current medications: What, why, type, dose, frequency, form, results, reactions, Rx (by whom), over the counter (include: anthelmintics, preventative, supplements, vitamins, etc.)
• Husbandry/care/sanitation/grooming management: What, who, when, how often?
• Tests: Clinical and diagnostic laboratory, imaging, etc.
• Vaccinations: Date, disease, type, brand, serial number, route of administration, etc.
• Geographical history
  • Travel:  Means of transportation, where, when, duration, why (ex. vacation, fair, show, training, breeding, boarding, etc.), contact with other animals
  • Geographic origin: Location (ex. humane shelter, neighboring farm, auction, pet shop, home farm raised, etc.)
  • Prior “ownership”: Who, where
  • Client or other human, animal, or other contacts from off or on the premises: (ex. Client was in a foreign country, visitor from another farm, visit to clinic, use of neighbor’s equipment, contact with wildlife or other domestic animals, ticks, mosquitoes, flies or other insects etc.)
• Environmental history:
  • Indoor, outdoor, or both
  • Tethered, free-roaming, fenced
  • Type of housing
  • Shade and protection from weather
  • Access to trash, chemicals, old painted surfaces (lead)
  • Water sources
  • Weather
  • Wetlands
  • Pasture type
• “Family” history:
  • Genetic defects
  • Infectious diseases (patient’s “littermates”)
  • Changes in or additions to other animals residing at same location
  • Changes and possible related health problems in human client family structure.

Past, Birth, and Referral History

Note: Many aspects of the current complaint history and status and past, birth, and referral history may be interrelated and overlap.

Objective

• To obtain information about the past, birth, and referral history of patient from the client.

What to Include

Past history:

• Medical
• Treatments and responses
• Surgical (including neutering, tail docking, ear cropping etc.)
• Trauma
• Vaccination/immunizations
• Diagnostic tests
• Medications
• Weight history
• Geographic history (travel) and origin
• Environmental
• Previous diet

Birth history: Where, when, complications, littermates (number and health status, if known), etc.

Referral history: Including referral practice

Patient Assessment

Objectives

• To collect and record the patient’s vital signs.
•  To observe, assess, and record the patient’s temperament, body systems, and general condition, using scoring systems where appropriate.
• To assist the veterinarian in establishing the diagnosis and prognosis.
• To determine the needs of the patient.

What to Include

In your patient can plan, include date about the patient. Data gathered as part of the patient assessment can be categorized as either objective or subjective:

Objective – Facts that are not influenced by personal feelings or interpretations.

Subjective – A perception or characteristic of the patient that is based on the evaluator’s observations.

In addition to objective and subjective information, be sure to include the following pieces of information:

Weight: Specify units.

Condition: Evaluate general appearance, and include Body Condition Score, Locomotion Score, and other appropriate scores.

Temperament: Record patient behavior.

Vital signs: Collect and record temperature, pulse, respiration, capillary refill time, mucus membrane color, mucus membrane moistness, skin turgor, and eyeball recession.

DVM/VMD exam and veterinary technician’s systems observations:

• Record whether systems (e.g. digestive, circulatory, nervous, etc.) have been examined or not, and describe as normal or abnormal.
• Record test results.
• Report abnormal findings or “normal” findings that are unique and/or discriminating for particular patient.

Things to Remember

A need is likely more routine or preventative in nature. Evaluate the need with a risk assessment which is virtually the same thing as acquiring a history.

Animals have “signs” (an objective observation), not “symptoms” (complaint by human patient).

The DVM/VMD, not the veterinary technician, makes all diagnoses and prognoses; prescribes tests, treatment and medication; performs surgeries ;etc. The veterinary technician does not diagnose but makes comments or observations regarding patient and patient body systems.

Technician Evaluation

Objective

• To identify abnormalities, events, or phenomena that require nursing intervention or action by the veterinary technician.
• To carry out diagnostic and therapeutic procedures prescribed by the DVM/VMD.

What to Include

Technical evaluations are problems and needs are identified based on the following:

• the client’s primary complaint and history
• the DVM/VMD’s diagnosis and prescription
• the veterinary technician's assessment
• hospital protocol
• good husbandry and care practices
• commonly accepted nursing practices. 

List and number the technician evaluation of problems and needs in the order of immediacy from most to least critical.

Note the date when each problem is identified and when it is resolved.

Sample Technical Evaluation

The following is an example of how a technician evaluates a patient.

The DVM/VMD diagnoses the presence of mastitis in a cow. According to the client’s report and observations made by the veterinary technician (VT) and DVM/VMD, the cow’s udder is swollen and congested. The DVM/VMD orders a culture and sensitivity test.

Interventions

Objective

• To discern what nursing steps need to be taken in order to fulfill patient needs and mitigate current or future problems.

What to Include

Interventions are defined as nursing and prescribed medical actions carried out by the veterinary technician (VT) to resolve the patient’s problems and care for the patient’s needs.

Similar to problems and needs, interventions can also be classified as either medical (DVM prescription) or nursing (VT). They may be exclusively nursing in nature or integrated with the actions of other members of the veterinary care team.

Interventions may involve the following:

• providing professional support to the DVM/VMD
• executing appropriate steps of hospital protocol/standard operating procedure (SOP)
• performing commonly accepted nursing and husbandry practices
• maintaining the patient’s comfort.  

List and number interventions according to which problems or needs they address. Intervention 1, therefore, should correspond to Problem 1.

Example “Interventions” List

The following is an example of how interventions may be recorded. This list is a continuation of the mastitis cow care plan, and the numbered interventions correspond with the problems and needs listed in the previous section.

Note: In emergency situations, the VT may be required to take action immediately, without a written plan. However, in less urgent contexts, planning and recording interventions are important aspects of providing appropriate care.

Rationale for Interventions

Note: Giving the rationale for each intervention is not always required as part of a patient care plan. This section is included primarily for educational purposes.

Objective

• To highlight the knowledge of why you are carrying out an intervention and how the patient is expected to respond.

What to Include

The rationale for an intervention is the medical, nursing, husbandry, physiological, or pathophysiological reason why the intervention is carried out.

In academic contexts, give references for the rationale.

List and number the rationale according to the corresponding problem and intervention.

Sample “Rationale for Interventions” List

The following list is a continuation of the mastitis cow care plan above, and the numbered rationale corresponds with the interventions listed in the previous section.

Continued Patient Reassessment

Objective

• To continually reassess and revise a patient's condition and the accompanying documentation.

What to Do

Patient care over a period of time is a continual process that is not static or linear. The patient's needs fluctuate and treatment plans evolve as the patient responds to treatment. This fluctuation obliges the veterinary technician to constantly reassess the patient, amend technician evaluations as needed, and record all changes in the medical record as they occur. The flow chart below illustrates this process (image created by Margaret Lump, BS, RVT).

After all data has been collected and recorded from the veterinary techician's (VT) examination of the patient, the DVM’s examination, laboratory results, medical records, and the observations of the owner, the VT identifies the patient’s needs and determine the appropriate interventions. While a diagnosis can only be made by the DVM—who is trained and licensed to determine the cause of a particular set of signs—the VT can make judgments about the patient’s response to these signs. The VT should also anticipate possible complications and/or future conditions and identify proper interventions accordingly. In emergency situations, the VT may be required to plan and carry out interventions immediately and without a written care plan, but in all other cases, it is important that the VT document each of the five sections below in order to provide optimum care.

• Make a list of the patient’s technician evaluations, ordered from the highest to lowest priority.
• Draw up a list of nursing (VT) and medical (DVM) interventions corresponding to the patient’s problems and needs. Identify each intervention as either nursing (VT) or medical (DVM).
• Provide the rationale for each intervention (in an academic environment, it may be necessary to include references to relevant sources).
• Draw up a list of the desired resolutions that could arise as a result of the interventions. Also identify the steps to treat and mitigate the effects of potential problems.
• Develop patient discharge plans, giving specific criteria of what observable signs would indicate the patient’s progress and/or full recovery. Note the negative responses that would be cause for alerting the DVM/VMD.

Example

The following example outlines continued assessment of the mastitis cow care plan mentioned above.

Desired Resolutions

Objective

• To identify the desired outcome for the patient, influenced by the technician’s intervention.

What to Include

The goals should be objective, descriptive, and/or measurable. They should describe what observable signs the patient exhibits as progress is made.

The patient’s desired resolution includes, but is not limited to, the following:

• vital signs within acceptable ranges
• a successful outcome for the specific condition
• changes in patient status

Avoid using terms such as “normal.” Instead, describe the patient, body part, or condition.

Example "Desired Resolutions"

Returning to the case of the mastitis cow, the following are examples of a desired resolution:

Progress Notes

Objectives

• To accurately monitor, assess, and record the patient’s progress.
• To determine whether the patient is achieving the ideal responses and report progress, relapses, or new problems to the veterinarian.
• To perform technician evaluation and intervention sequence for all new problems.
• To list all resolved problems and needs.

What to Include

Documentation of all actions and interventions, including:

• Doses of medication
• Procedures

Documentation of all patient responses, including:

• Any observations related to technician evaluations
• Problems that have been resolved
• Disease and treatment sequelae (begin new intervention sequence)

Note: All entries should include the date and time of the entry as well as the initials of the veterinary technician.

Example "Progress Notes"

Returning to the case of the mastitis cow, the following are examples of notes that would be included as you monitor and document the patient’s progress.

Discharge Planning

Objectives

• To develop client education information and discharge plan.
• To make sure client is in agreement with and competent to accomplish the home care procedures. (Note: This is an important part of compliance and the ethical requirements of the veterinarian-client-patient relationship) 

What to Include

When creating a discharge plan, be sure to include the following:

• Client education regarding the patient, their problems and needs, and description of what to do, how to do it, and what not to do
• History of the hospitalization and an explanation of test data and in-hospital procedures
• Home care instructions and criteria for monitoring (may include demonstration of, and/or testing of client’s ability to perform home care procedures)
• Expenses, charges, and fees
• Follow-up visits
• Potential problems
• Medication preparations, administration and storage
• Pharmaceutical side effects
• Withdrawal/withholding times
• Zoonotic potential and how to prevent it
• Recourses for the client who lacks the ability to comply
• Address any questions the client may have regarding the patient
• Emergency and callback procedures

Important Steps and Procedures in Creating a Discharge Plan

1. Begin the client education information and discharge plan upon admission of patient and modify it throughout the course of the outpatient visit or hospitalization.

2. Use terminology that is clear and easy for the client to understand.

3. Give client a written copy of the plan and have them sign off on it, attesting to their understanding and acceptance of the conditions of treatment (witnessed by a veterinary health care team member).

Legal Issues of Documentation

Because the veterinary medical record is a legal document, the following principles should be strictly adhered to when writing in the record:

• The patient’s name and species and the owner’s name must be clearly written. Include this information on every page of the record.
• Use black ink if the entries are handwritten.
• Note the date and time at the beginning of each entry. The person making the entry should record his/her name and position at the end.
• If an incorrect entry is made, draw a single line through the mistake. Write “error,” the name of the person making the change, the reason for correction, and the date next to the entry. Do not erase or obliterate any part of the record.
• If a digital record-keeping system is used, the changes must be traceable and recorded in a manner similar to handwritten records.
• Every aspect of a patient’s care must be documented. Legally, it is virtually impossible to prove a certain action was taken unless it was documented in the record.

Records are the legal property of the veterinary hospital and/or veterinarian(s) who own the practice. Information about a patient may only be released to the client at the discretion of the attending veterinarian. The client has a right to access all the information in the records. 

*Some materials adapted from Rockett, J. et al. (2009). Patient Assessment, Intervention, and Documentation for the Veterinary Technician. Clifton Park, NY: Delmar.

Sample Care Plan Example

The PDF in this resource provides one example of a care plan. This sample is not a template. Please follow your instructor's guidelines for creating a sample care plan.