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Veterinary Medicine Specialist
10-15 minutes

Veterinary SOAP Record

The s10.ai Vet SOAP Note template is an all-encompassing documentation solution crafted for veterinarians to meticulously document observations and evaluations during animal check-ups. This template is perfect for logging vital signs, medical history, physical examination results, and assessments in an organized manner. Veterinarians can leverage this template to guarantee comprehensive documentation of every visit, enhancing communication with pet owners and promoting seamless continuity of care.

1,843 uses
4.2/5.0
D
Dr. Natalie Brooks
Template Structure

Organized sections for comprehensive clinical documentation

Vital Parameters:
- Temperature: [Temperature reading or state not taken] (leave blank if not mentioned)
- Heart Rate: [Pulse rate or state not taken] (leave blank if not mentioned)
- Breathing Rate: [Respiratory rate or state not taken] (leave blank if not mentioned)
Medical History:
- [Summary of the reason for the current visit] (include only if explicitly mentioned)
- [Dietary habits] (include only if explicitly mentioned)
- [Energy levels] (include only if explicitly mentioned)
- [Any current or past medical issues] (include only if explicitly mentioned)
Physical Examination Observations:
- Body Condition Score: [Body Condition Score] (include only if explicitly mentioned)
- Mental Status: [Mental status or state] (include only if explicitly mentioned, otherwise state "BAR")
- Behavior: [Behaviour during examination] (include only if explicitly mentioned, otherwise state "Friendly and tolerant")
Ocular Assessment:
- [Eye examination findings] (populate with "Corneas clear. No ocular discharge present. No redness or blepharospasm noted. Conjunctiva normal." if not mentioned)
Auditory Assessment:
- [Ear examination findings] (populate with "Ears are clean and free of debris. No sign of otitis externa. No redness or erythema noted of pinna or ear canal." if not mentioned)
Mucous Membranes:
- [Mucous membrane assessment] (populate with "pink and moist" if not mentioned)
Capillary Refill Time:
- [Capillary refill time] (populate with "<2 sec" if not mentioned)
Oral Examination:
- [Dental health assessment and recommendations] (populate with "Acceptable occlusion. No dental tartar or gingivitis noted on examination." if not mentioned)
- [Oral cavity examination findings] (include only if explicitly mentioned)
Lymphatic System:
- [Lymph node examination findings] (populate with "No abnormalities on palpation of mandibular, prescapular or popliteal lymph nodes." if not mentioned)
Cardiovascular System:
- [Cardiovascular system assessment] (populate with "Normal, no audible murmur noted on auscultation. Good rhythm and rate. Femoral pulses present and synchronous." if not mentioned)
Respiratory System:
- [Respiratory system assessment] (populate with "Normal auscultation all fields. No wheezes or crackles appreciated. Normal inspiratory and expiratory effort. Tracheal palpation elicited no response. No coughing or sneezing noted by owner or in exam room. No nasal discharge present." if not mentioned)
Abdominal Examination:
- [Abdominal examination findings] (populate with "No discomfort on abdominal palpation. Abdomen soft. No pain/guarding/splinting noted on palpation. No masses, organomegaly or distention appreciated. Auscultation normal." if not mentioned)
Musculoskeletal System:
- [Musculoskeletal system assessment] (populate with "Ambulating normally throughout exam. Normal ROM all limbs, no swelling or discomfort on palpation of limbs and joints." if not mentioned)
Skin and Coat:
- [Skin and coat assessment] (populate with "No masses or lesions found. Normal skin tent. Good coat." if not mentioned)
Urogenital System:
- [Urogenital system assessment] (populate with "Normal; no inflammation or discharge." if not mentioned)
Neurological System:
- [Neurological examination findings] (populate with "Normal conscious proprioception and mentation. No neuro exam performed." if not mentioned)
Rectal Examination:
- [Rectal examination findings or state not performed] (include only if explicitly mentioned)
Diagnostic Findings:
- [Summary of any diagnostic tests performed or state none performed] (include only if explicitly mentioned)
Clinical Assessment:
- Problem list:
1. [First problem identified] (include only if explicitly mentioned)
2. [Second problem identified] (include only if explicitly mentioned)
3. [Third problem identified] (include only if explicitly mentioned)
4. [Fourth problem identified] (include only if explicitly mentioned)
5. [Fifth problem identified] (include only if explicitly mentioned)
- [Additional problems if any] (use as many bullet points as needed)
Treatment Plan:
- [Medications prescribed or sent home] (include only if explicitly mentioned)
- [Follow-up care or additional recommendations] (include only if explicitly mentioned)
Communication Notes:
- [Summary of discussions with the owner regarding treatments] (include only if explicitly mentioned)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, or plan for continuing care. Use only the transcript, contextual notes, or clinical note as a reference. Leave placeholders blank if not explicitly mentioned.)
Sample Clinical Note

Example of completed documentation using this template

Vital Signs:
- Temp: 101.5°F
- Pulse: 80 bpm
- Respiratory Rate: 20 breaths/min
History:
- Bella, a 5-year-old Labrador Retriever, came in for her yearly wellness check. The owner notes no changes in eating habits and reports a high energy level. No current or previous medical issues were identified.
Physical Exam Findings:
- BCS: 5/9
- Mentation: BAR
- Behaviour: Friendly and tolerant
Eyes:
- Corneas are clear. No ocular discharge observed. No redness or blepharospasm noted. Conjunctiva appears normal.
Ears:
- Ears are clean and free of debris. No signs of otitis externa. No redness or erythema noted in the pinna or ear canal.
MM:
- Pink and moist
CRT:
- <2 sec
Oral Cavity:
- Acceptable occlusion. No dental tartar or gingivitis observed during examination.
Lymph Nodes:
- No abnormalities detected on palpation of mandibular, prescapular, or popliteal lymph nodes.
Cardiovascular:
- Normal, no audible murmur detected on auscultation. Good rhythm and rate. Femoral pulses present and synchronous.
Respiratory:
- Normal auscultation in all fields. No wheezes or crackles detected. Normal inspiratory and expiratory effort. Tracheal palpation elicited no response. No coughing or sneezing noted by owner or in exam room. No nasal discharge present.
Abdomen:
- No discomfort on abdominal palpation. Abdomen soft. No pain/guarding/splinting noted on palpation. No masses, organomegaly, or distention detected. Auscultation normal.
Musculoskeletal:
- Ambulating normally throughout exam. Normal ROM in all limbs, no swelling or discomfort on palpation of limbs and joints.
Integument:
- No masses or lesions found. Normal skin tent. Good coat.
Urogenital:
- Normal; no inflammation or discharge.
Neurological:
- Normal conscious proprioception and mentation. No neuro exam performed.
Rectal Exam:
- Not performed
Diagnostic Results:
- None performed
Assessment:
- Problem list:
  1. None identified
Plan:
- No medications prescribed. Continue current diet and exercise routine. Schedule next wellness exam in one year.
Communications:
- Discussed with the owner the importance of maintaining Bella's current diet and exercise routine to ensure continued health.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The Vital Signs and Physical Exam Findings template is an essential tool for healthcare professionals seeking to streamline patient assessments and documentation. This comprehensive template covers critical areas such as vital signs, history, physical exam findings, and system-specific evaluations, ensuring a thorough and organized approach to patient care. With sections dedicated to cardiovascular, respiratory, musculoskeletal, and neurological assessments, clinicians can efficiently document and monitor patient health. The template's structured format allows for easy integration into electronic health records, enhancing workflow efficiency and accuracy. By adopting this template, healthcare providers can improve patient outcomes through consistent and detailed clinical documentation, ultimately leading to better-informed treatment decisions and enhanced patient care.
Frequently Asked Questions

Common questions about this template and its usage

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Veterinary SOAP Record