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History, Presenting Chief Complaint

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.

Contributors:Natalie van Hoose, April Phillips, Jamelyn Schoenbeck Walsh, Margaret Lump, Elizabeth Angeli
Last Edited: 2012-03-11 03:24:38

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:

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