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Patient Signalment, Client Information

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 03:25:34

Objectives

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

Species

Breed

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:

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