History, Presenting Chief Complaint
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.
Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli
Last Edited: 2016-06-14 21:17:01
- 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:
"The vomit contained whole food and watery fluid."
"Fido has violent retching followed by projectile vomiting."
"The vomiting started yesterday morning."
"Fido has been vomiting for about a week."
- Time of day
"Fido vomits mostly in the morning."
"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.