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Continued Patient Reassessment

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: 2012-03-16 14:03:15

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.

 

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