Patient Signalment, Client Information
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: 2012-03-11 03:25:34
- To collect, classify, and record required patient information.
- To identify the relevance and interrelationship of the information as it relates to:
- 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
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