Veterinarian SOAP Note (custom)

TPR: - Temp: [Temperature reading or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Pulse: [Pulse rate or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Respiratory Rate: [Respiratory rate or state not taken] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History: - [Summary of the reason for the current visit] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Dietary habits] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Energy levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Any current or past medical issues] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) General Physical Exam : - BCS: [Body Condition Score] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Mentation: [Mental status or state] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - Behaviour: [Behaviour during examination] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Eyes: - [Eye examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Ears: - [Ear examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) MM: - [Mucous membrane assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) CRT: - [Capillary refill time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Oral Cavity: - [Dental health assessment and recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Oral cavity examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Lymph Nodes: - [Lymph node examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Cardiovascular: - [Cardiovascular system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Respiratory: - [Respiratory system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Abdomen: - [Abdominal examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Musculoskeletal: - [Musculoskeletal system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Integument: - [Skin and coat assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Urogenital: - [Urogenital system assessment] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Neurological: - [Neurological examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Rectal Exam: - [Rectal examination findings or state not performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnostic Results: - [Summary of any diagnostic tests performed or state none performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Assessment Summary: • [First problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • [Second problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • [Third problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • [Fourth problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • [Fifth problem identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) • [Additional problems if any] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Tx and Management Plan : - [Medications prescribed or sent home] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [Follow-up care or additional recommendations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Discussion: - [Summary of discussions with the owner regarding treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)