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Desired Resolutions

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 14:03:27

Objective

What to Include

The goals should be objective, descriptive, and/or measurable. They should describe what observable signs the patient exhibits as progress is made.

The patient’s desired resolution includes, but is not limited to, the following:

Avoid using terms such as “normal.” Instead, describe the patient, body part, or condition.

Example "Desired Resolutions"

Returning to the case of the mastitis cow, the following are examples of a desired resolution:

Milk returns to a consistency that is not watery, ropey, or clumped.
Milk is white in color and not tinged with blood.
T: 100-102.5, P: 55-80, R: 10-30, MMC: Pink, MMM: Moist, CRT: <2 sec., Skin Turgor: <2 sec.
Udder is pliable post-milking and is no colder or warmer than other quadrants of the udder. areas of the lower abdomen.
Milk sample has no drug residues.

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