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Patient Assessment

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 02:08:37

Objectives

What to Include

In your patient can plan, include date about the patient. Data gathered as part of the patient assessment can be categorized as either objective or subjective:

Objective – Facts that are not influenced by personal feelings or interpretations.

Examples: laboratory results, weight, vital signs

Subjective – A perception or characteristic of the patient that is based on the evaluator’s observations.

Examples: body condition score, pain scale rating, temperament

In addition to objective and subjective information, be sure to include the following pieces of information:

Weight: Specify units.

Condition: Evaluate general appearance, and include Body Condition Score, Locomotion Score, and other appropriate scores.

Temperament: Record patient behavior.

Vital signs: Collect and record temperature, pulse, respiration, capillary refill time, mucus membrane color, mucus membrane moistness, skin turgor, and eyeball recession.

DVM/VMD exam and veterinary technician’s systems observations:

Example: A horse with colic may attempt to roll as a sign of more severe pain. It might therefore be significant if a horse with colic is not attempting to roll as it may indicate less severe pain. 

Things to Remember

A need is likely more routine or preventative in nature. Evaluate the need with a risk assessment which is virtually the same thing as acquiring a history.

Animals have “signs” (an objective observation), not “symptoms” (complaint by human patient).

The DVM/VMD, not the veterinary technician, makes all diagnoses and prognoses; prescribes tests, treatment and medication; performs surgeries ;etc. The veterinary technician does not diagnose but makes comments or observations regarding patient and patient body systems.

Example: Write, “Mucus membranes were tacky, skin tented for 3 seconds, eyeballs recessed” not “patient was dehydrated” (this last statement is a diagnosis made by DVM).

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