Vet Intake Note

**PATIENT:** [Patient ID] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Age, date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Sex, neutering status] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Weight: [Weight] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Microchip number: [Microchip number] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **VISIT:** Reason: [Reason for visit] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Veterinarian: [Veterinarian name and credentials] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Check in: [Check in date and time] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Check out: [Check out date and time] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Referring practice: [Referring practice name] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **SUBJECTIVE:** **History:** [Patient history including age, species, breed, reason for presentation, condition being monitored, owner observations and comments] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) **Current medications:** [List of current medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **OBJECTIVE:** **Vitals:** - Temperature: [Temperature] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Heart rate: [Heart rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Respiratory rate: [Respiratory rate] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Weight: [Weight] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Physical exam:** - General appearance: [General appearance observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - EENT: [Eyes, ears, nose, and throat observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Oral cavity: [Oral cavity observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - CV: [Cardiovascular system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Resp: [Respiratory system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Neuro: [Neurological system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Integument: [Integumentary system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Abdomen/GI: [Abdominal and gastrointestinal system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Musculoskeletal: [Musculoskeletal system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Urogenital: [Urogenital system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Lymph: [Lymphatic system observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Rectal: [Rectal exam observations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Diagnostic results:** - [List of diagnostic results as stated by the clinician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **ASSESSMENT:** - [Assessment based on subjective and objective findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **PLAN:** **Diagnostic/Treatment plan:** - [Outline plan for ongoing treatment, medications, procedures, or further diagnostics] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.) **Recommendations:** - [List of recommendations] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points.)