Veterinarian Template

Progress Review

A professional Veterinarian template for healthcare professionals.

About this template

Need a clear and concise way to document your veterinary patient's progress? Our 'Progress Review' template is perfect for veterinarians. This template helps you create detailed notes, covering everything from the animal's history and current status to their mood, social life, and physical health. It's designed to ensure you capture all the essential information in a structured format, making it easy to track changes and provide the best care. This template is ideal for any vet looking to improve their documentation process and keep accurate records of their patients' health journeys.

Preview template

#PROGRESS NOTE 01 November 2024 Introduction: [Patient Name], a 5-year-old Golden Retriever, is presented today with their owner, [Owner Name]. The dog lives in a suburban home with a fenced yard and is generally active and well-cared for. Patient’s History and Current Status: [Patient Name] has a history of mild seasonal allergies, managed with over-the-counter antihistamines. The dog is up-to-date on all vaccinations and is on a monthly heartworm preventative. There have been no recent changes in diet or exercise. The owner reports no significant changes in the dog's behaviour or appetite. Presentation in Clinic: [Patient Name] appeared bright, alert, and responsive during the examination. The dog was accompanied by [Owner Name], who was cooperative and provided a detailed history. The dog's coat was shiny, and the body condition score was ideal. The dog was friendly and allowed a full physical examination without issue. Mood and Mental State: The dog displayed a happy and relaxed demeanour throughout the visit. There were no signs of anxiety or distress. The dog was eager to interact and showed no signs of aggression. Social and Functional Status: [Patient Name] enjoys regular walks and playtime in the park. The dog interacts well with other dogs and people. The owner reports that the dog is well-behaved at home and follows commands. The dog is not currently enrolled in any specific training programs. Physical Health Issues: The dog's physical examination revealed no immediate concerns. The dog's weight is appropriate for its breed and age. The owner was advised to continue with regular dental care, including brushing the dog's teeth at home. The dog is under the care of a general practitioner for routine check-ups and vaccinations. Plan and Recommendations: 1. Continue with the current diet and exercise regimen. 2. Administer monthly heartworm preventative as prescribed. 3. Continue with regular dental care, including brushing the dog's teeth at home. 4. Schedule a follow-up appointment in six months for a routine check-up and vaccinations. 5. Monitor for any signs of allergies and administer antihistamines as needed. Closing Statement: The owner was advised to maintain a consistent routine for the dog, including regular exercise and a balanced diet. The importance of dental care was emphasized. The owner was encouraged to contact the clinic if any concerns arise before the next scheduled visit.

#PROGRESS NOTE [date of note] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in format: DD Month YYYY.) [introduction including patient’s age, marital status, and living situation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) [history and current status, including relevant chronic conditions, psychiatric diagnoses, treatment history, and any stabilising interventions such as medication or psychotherapy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) [presentation in clinic including physical appearance, attendance details, cooperation, and general demeanour] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) [mood and mental state, including mood stability and emotional state as described by the patient or observed during the session] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) [social and functional status, including quality of relationships, participation in support programs (e.g., NDIS), ability to manage daily responsibilities, and support from others such as spouse or carer] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) [physical health issues, including any diagnoses or concerns, medical follow-up, and advice given] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) Plan and Recommendations: 1. [treatment continuation or change, including medications and therapies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as single line.) 2. [recommendation to maintain ongoing support programs such as NDIS] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as single line.) 3. [any health-related advice provided, such as hydration or lifestyle tips] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as single line.) 4. [follow-up plan including timing and purpose of review] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as single line.) [closing statement including final recommendations or reassurance provided to the patient] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a paragraph of full sentences.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.) (Ensure that every section is written in full sentences and paragraphs, capturing all relevant details in a narrative style.)

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