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Veterinary Medicine Specialist
10-15 minutes

Veterinary Hospitalization SOAP Note

The Veterinary Hospitalisation SOAP Note template by s10.ai is expertly crafted for veterinarians in emergency care environments, offering a systematic approach to documenting patient assessments, including vital signs, diagnostic evaluations, and treatment strategies. This template is perfect for capturing detailed clinical data during hospital stays, ensuring seamless continuity of care. Veterinarians can utilize this template to effectively document and convey patient conditions and therapeutic measures, thereby elevating the standard of care delivered. Optimized for integration with AI medical scribe software like s10.ai, this template significantly streamlines the documentation workflow in bustling veterinary settings.

1,818 uses
4.2/5.0
J
Jordan Kim
Template Structure

Organized sections for comprehensive clinical documentation

(You are a senior veterinarian employed at an emergency veterinary hospital)
Reason: [Explain the referral reason and any pertinent history provided by the owner]
Time: [Consultation time]
Objective:
- Bodyweight: [Patient's weight in kg]
- Demeanour: [Patient's general demeanor description]
- TPR:
- HR: [Heart rate (beats per minute)]
- RR: [Respiratory rate per minute]
- MM Colour: [Color of mucous membranes]
- CRT: [Capillary refill time]
- Temp: [Temperature] (Record in Celsius)
- Blood pressure: [Blood pressure]
- CVS: [Cardiovascular system findings] (if not mentioned write "No significant findings on auscultation. Pulses normal")
- Resp: [Respiratory system findings] (if not mentioned write "No significant findings on auscultation. Normal respiratory rate and character at rest.")
- Abdo/ALI: [Abdominal and alimentary system findings] (if not mentioned write "No significant findings. Comfortable on abdominal palpation")
- Catheter Site: [Catheter site assessment] (if not mentioned write "No significant findings. Catheter patent") (Do not include if there is mention that the patient does not have a catheter)
- Hydration: [Hydration status] (if not mentioned "No significant findings. No evidence of hypovolaemia or dehydration")
Diagnostics:
- [Diagnostic tests and results] (Use as many bullet points as required)
Assessment:
- [Clinical assessment and findings] (write in full sentences and do not use bullet points)
Treatment:
- [Treatment/interventions provided to the patient] (Always include "refer to flowsheet for full treatment plan") (Use as many bullet points as required)
Plan:
- [Plan for ongoing care and follow-up] (if not mentioned write "continue hospitalisation until fit for discharge")
Sample Clinical Note

Example of completed documentation using this template

Reason: Bella, a 5-year-old Labrador Retriever, was referred for assessment due to ongoing vomiting and lethargy over the last 48 hours. The owner mentioned that Bella had swallowed a foreign object during a walk.
Time: 14:30
Objective:
- Bodyweight: 30 kg
- Demeanour: Alert but slightly lethargic
- TPR:
- HR: 110 beats per minute
- RR: 24 per minute
- MM Colour: Pink
- CRT: 1.5 seconds
- Temp: 38.5°C
- Blood pressure: 120/80 mmHg
- CVS: No significant findings on auscultation. Pulses normal
- Resp: No significant findings on auscultation. Normal respiratory rate and character at rest.
- Abdo/ALI: Mild discomfort on abdominal palpation, possible foreign body palpable
- Catheter Site: No significant findings. Catheter patent
- Hydration: Mild dehydration noted
Diagnostics:
- Abdominal X-ray: Foreign object detected in the stomach
- Bloodwork: Elevated white blood cell count
Assessment:
Bella is experiencing gastrointestinal distress likely due to the ingestion of a foreign object. The presence of the object in the stomach is causing vomiting and mild dehydration.
Treatment:
- Administered IV fluids to address dehydration
- Initiated antiemetic therapy
- Scheduled for endoscopic retrieval of the foreign object
- Refer to flowsheet for full treatment plan
Plan:
- Continue hospitalisation until fit for discharge
- Monitor hydration status and adjust fluid therapy as needed
- Re-evaluate post-endoscopy for any complications
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your veterinary emergency practice with our comprehensive clinical template designed to streamline patient assessments and improve documentation accuracy. This template is meticulously crafted to capture essential patient data, including referral reasons, consultation timing, and detailed objective findings such as bodyweight, demeanor, and vital signs like heart rate, respiratory rate, and temperature. It also covers cardiovascular, respiratory, and abdominal system evaluations, ensuring no significant findings are overlooked. With sections dedicated to diagnostics, clinical assessments, and treatment plans, this template facilitates thorough and efficient patient care. Encourage seamless communication and continuity of care with a structured plan for ongoing treatment and follow-up. Adopt this template to enhance clinical efficiency, ensure comprehensive patient evaluations, and optimize your veterinary emergency services.
Frequently Asked Questions

Common questions about this template and its usage

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