Veterinarian Template

Vet SOAP Note

A professional Veterinarian template for healthcare professionals.

About this template

Streamline your veterinary practice's record-keeping with our comprehensive Vet SOAP Note template. Designed specifically for animal healthcare professionals, this template ensures all crucial aspects of a patient's visit are meticulously documented, from detailed history and vital signs to physical exam findings across all body systems. Ideal for busy vets, vet nurses, and anyone involved in animal care, this "veterinary SOAP note example" helps maintain thorough and organised patient records. Heidi, our AI medical scribe, can effortlessly populate this template using your consultation transcripts, ensuring consistent, accurate, and time-saving documentation for every animal patient. Improve your clinic's efficiency and patient care with structured, easy-to-read clinical notes.

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Vet SOAP Note - Veterinarian History: - Summary of reason for current visit: "Buster", a 5-year-old male neutered Golden Retriever, presented for acute onset of lethargy, decreased appetite, and intermittent vomiting for the past 24 hours. Owner reports no known exposure to toxins or dietary indiscretion. - Dietary habits: Fed Royal Canin adult dog food twice daily, no recent changes. Occasionally receives dental chews. - Energy levels: Significantly decreased compared to usual. Normally very active. - Current or past medical issues: Previously healthy, up to date on vaccinations and parasite prevention. Vital signs: - Temp: 39.5°C (mildly elevated) - Heart rate: 108 bpm (WNR) - Respiratory rate: 24 bpm (WNR) Physical exam findings: - BCS: 5/9 (Ideal) - Mentation: QAR (Quiet, alert, responsive) - Behaviour: Slightly subdued but cooperative during examination. Eyes: - Clear, no discharge or conjunctival injection. Pupils equally reactive to light. Ears: - Clean, no discharge, odour, or signs of inflammation. Pinnae healthy. Oral cavity: - Mucous membranes assessment: Pink and moist. - Capillary refill time: <2 seconds. - Dental health assessment and recommendations: Mild gingivitis noted. Recommendation for dental cleaning in the next 6-12 months. - Oral cavity examination findings: No foreign bodies or oral lesions observed. Lymph nodes: - All peripheral lymph nodes non-palpable and within normal limits. Cardiovascular: - Cardiovascular system assessment: Normal heart sounds, no murmurs or arrhythmias detected. - Pulse assessment: Strong and synchronous femoral pulses. Respiratory: - Respiratory system assessment: Clear lung sounds bilaterally, no increased respiratory effort. Abdomen: - Abdominal palpation findings and assessment: Mild cranial abdominal discomfort on deep palpation. No palpable masses or organomegaly. Musculoskeletal: - Musculoskeletal system assessment: Ambulatory x 4, no lameness or pain on palpation of limbs or spine. Integument: - Skin and coat assessment: Healthy coat, no lesions, parasites, or alopecia noted. Skin turgor normal. Urogenital: - Urogenital system assessment: Normal external genitalia. No issues reported by owner. Neurological: - Neurological examination findings: Cranial nerves intact, normal gait and reflexes. No proprioceptive deficits. Rectal exam: - Rectal examination findings or state not performed: Not performed at this visit. Diagnostic results: - Summary of any diagnostic tests performed or state none performed: In-house CBC revealed mild leukocytosis with a left shift. Chemistry panel showed mild elevation in ALT. Urinalysis pending. Assessment: - Problem list: 1. Vomiting/anorexia 2. Lethargy 3. Mild leukocytosis with left shift 4. Mild ALT elevation 5. Mild gingivitis Plan: - Medications prescribed or sent home: Maropitant 16mg SC in clinic, then 8mg PO SID for 3 days. Metronidazole 250mg PO BID for 5 days. Cerenia tablets sent home. - Follow-up care or additional recommendations: Recheck in 48 hours or sooner if symptoms worsen. Discussed feeding bland diet (boiled chicken and rice) for 3-5 days. Owner to call with urinalysis results once received. Communications: - Summary of discussions with owner regarding treatments: Discussed possible causes of vomiting (gastritis vs. early pancreatitis vs. other). Explained diagnostic findings and treatment plan. Owner understands the need for close monitoring and follow-up.

History: - [Summary of reason for current visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Dietary habits] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Energy levels] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Current or past medical issues] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Vital signs: - Temp: [Temperature] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. State "WNR" if within normal range.) - Heart rate: [Heart rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. State "WNR" if within normal range.) - Respiratory rate: [Respiratory rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. State "WNR" if within normal range.) Physical exam findings: - BCS: [Body condition score] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Mentation: [Mentation status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Behaviour: [Behaviour during examination] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Eyes: - [Eye examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Ears: - [Ear examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Oral cavity: - [Mucous membranes assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Capillary refill time] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Dental health assessment and recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Oral cavity examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Lymph nodes: - [Lymph nodes assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Cardiovascular: - [Cardiovascular system assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Pulse assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Respiratory: - [Respiratory system assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Abdomen: - [Abdominal palpation findings and assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Musculoskeletal: - [Musculoskeletal system assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Integument: - [Skin and coat assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Urogenital: - [Urogenital system assessment] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Neurological: - [Neurological examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Rectal exam: - [Rectal examination findings or state not performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Diagnostic results: - [Summary of any diagnostic tests performed or state none performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Assessment: - Problem list: 1. [First problem identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 2. [Second problem identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 3. [Third problem identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 4. [Fourth problem identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) 5. [Fifth problem identified] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Additional problems if any] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Continue numbering.) Plan: - [Medications prescribed or sent home] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Follow-up care or additional recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Communications: - [Summary of discussions with owner regarding treatments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)

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