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Progress Notes

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 14:03:35

Objectives

What to Include

Documentation of all actions and interventions, including:

Documentation of all patient responses, including:

Note: All entries should include the date and time of the entry as well as the initials of the veterinary technician.

Example "Progress Notes"

Returning to the case of the mastitis cow, the following are examples of notes that would be included as you monitor and document the patient’s progress.

4:50PM 9/10/05 T 103.5, P 70, R 10, MMC pale, MMM dry, skin turgor: 4+ sec, CRT: 3 sec, udder hot and hard djw

5:15PM 9/10/05 Collected milk samples and set up culture and sensitivity 5:15PM 9/10/05djw

5:30PM 9/10/05 Ketones: 2+ were identified in milk and urine djw

6PM 9/10/05 Milked and striped quarters djw

7PM 9/10/05 Fed, watered, re-bedded stall, groomed, ate ~3 lbs of hay, drank ~1 gallon of water djw

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