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 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).