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Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

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:

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.

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Patient Signalment, Client Information

Objectives

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:

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

History, Presenting Chief Complaint

Objective

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.

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. 

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

Example: “The client saw the calf licking its side” not “The client said the calf was in pain because they saw it licking its side.”

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
 

"The last time Fido ate without vomiting was two days ago."

Anatomical location of the problem or body system affected

"Fido’s stomach grumbles prior to vomiting.

Character of the problem, including:

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Current Health Status, History

Objective

What to Include

Tailor this information to the species of the patient.

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

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

What to Include

Past history:

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

Referral history: Including referral practice

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Patient Assessment

Objectives

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.

Examples: laboratory results, weight, vital signs

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

Examples: body condition score, pain scale rating, temperament

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:

Example: A horse with colic may attempt to roll as a sign of more severe pain. It might therefore be significant if a horse with colic is not attempting to roll as it may indicate less severe pain. 

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.

Example: Write, “Mucus membranes were tacky, skin tented for 3 seconds, eyeballs recessed” not “patient was dehydrated” (this last statement is a diagnosis made by DVM).
Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Technician Evaluation

Objective

What to Include

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

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.

 

Technical Evaluations

1

Mastitis (DVM)

2

Congested udder (client, DVM, VT)

3

Poor husbandry (history, VT)

4

Poor milking practices (history, VT)

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Interventions

Objective

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:

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.

 

Problems and Needs

Interventions

1

Mastitis (DVM)

  • Conduct culture and sensitivity test (DVM)
  • Sanitize teat ends (VT)
  • Collect 4 quarter milk samples using accepted procedures (VT)
  • Administer prescribed medication based on test results and subsequent DVM Rx (DVM)
  • Warm pack and massage udder every six hours (VT)

2

Congested udder (client, DVM, VT)

3

Poor husbandry (history, VT)

  • Provide and maintain a clean, well-bedded stall (VT)
  • Provide free choice water (VT)
  • Provide palatable grass hay (VT)
  • Provide trace mineralized salt lick (VT)
  • Groom cow daily (VT)

4

Poor milking practices (history, VT)

  • Milk patient last (every 12 hours) (VT)
  • Sanitize udder and teats (VT)
  • Hand strip quarters (VT)
  • Dip teats (VT)
  • Inspect milking machines and evaluate practices (VT)

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.

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

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

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.

 

Interventions

Rationale for Interventions

1, 2

  • Conduct culture and sensitivity test (DVM)
  • Sanitize teat ends (VT)
  • Collect 4 quarter milk samples using accepted procedures (VT)
  • Administer prescribed medication based on test results and subsequent DVM Rx (DVM)
  • Warm pack and massage udder every six hours (VT)

Teat ends are sanitized to prevent iatrogenic infections and contamination of the milk samples with environmental organisms. Teats are sanitized from the farthest to nearest teat to limit the possibility of contamination while sanitizing. Individual quarter samples are collected to identify the causative organism in each quarter. Samples are collected from the nearest to farthest teat to limit the possibility of contamination in the collection process.

 

Reference: “Procedures for Collecting Milk Samples” (2004). Microbiological Procedures for the Diagnosis of Bovine Udder Infection (3rd ed.). National Mastitis Council. Retrieved from: www.nmconline.org/sampling.htm

 

Warmth and massage help increase circulation to the udder, thereby mitigating congestion.

 

Reference: Bassert, J.M. & McCurnin, D. M. (2002) Clinical Textbook for Veterinary Technicians (5th ed.). Philadelphia: Saunders.

3

  • Milk patient last (every 12 hours) (VT)
  • Sanitize udder and teats (VT)
  • Hand strip quarters (VT)
  • Dip teats (VT)
  • Inspect milking machines and evaluate practices (VT)

Milking cows with mastitis last in order helps prevent the spread of mastitis to other cows. Proper vacuum and sequencing of the milking machine, as well as fit and sanitation of teat cups, limits irritation and contamination of the teats.

 

Reference: Schroeder, J.W. (2010) Mastitis Control Programs: Bovine Mastitis and Milking Management. Retrieved from: http://www.ag.ndsu.edu/pubs/ansci/dairy/as1129w.htm

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Continued Patient Reassessment

Objective

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).

This image illustrates how to reassess a patient.

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.

Example

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

This image shows continued assessment of the mastitis cow care plan mentioned above.

 

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Desired Resolutions

Objective

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:

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:

Milk returns to a consistency that is not watery, ropey, or clumped.
Milk is white in color and not tinged with blood.
T: 100-102.5, P: 55-80, R: 10-30, MMC: Pink, MMM: Moist, CRT: <2 sec., Skin Turgor: <2 sec.
Udder is pliable post-milking and is no colder or warmer than other quadrants of the udder. areas of the lower abdomen.
Milk sample has no drug residues.
Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Progress Notes

Objectives

What to Include

Documentation of all actions and interventions, including:

Documentation of all patient responses, including:

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.

4:50PM 9/10/05 T 103.5, P 70, R 10, MMC pale, MMM dry, skin turgor: 4+ sec, CRT: 3 sec, udder hot and hard djw

5:15PM 9/10/05 Collected milk samples and set up culture and sensitivity 5:15PM 9/10/05djw

5:30PM 9/10/05 Ketones: 2+ were identified in milk and urine djw

6PM 9/10/05 Milked and striped quarters djw

7PM 9/10/05 Fed, watered, re-bedded stall, groomed, ate ~3 lbs of hay, drank ~1 gallon of water djw
Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

Discharge Planning

Objectives

What to Include

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

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).

 

 

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

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:

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.

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli .
Summary:

The intention of this section is 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.

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.