Veterinarian Template

Inpatient Daily Update (SOAP)

A professional Veterinarian template for healthcare professionals.

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Specialty

Veterinarian

Used

55 times

Type

Note

Last edited

25/06/2025

Created by

Mohamed Ismail

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About this template

This Inpatient Daily Update (SOAP) template is designed for veterinarians working in a hospital setting. It provides a structured format for documenting daily updates on hospitalized animal patients. The template includes sections for recording the reason for admission, vital signs, objective findings, diagnostics, assessment, treatment, and ongoing care plans. This template ensures comprehensive and consistent documentation, aiding in effective patient management and communication among veterinary staff. Ideal for use in veterinary hospitals, this template helps streamline the documentation process, ensuring all critical information is captured accurately.

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Reason: Vomiting and lethargy Time: 10:00 AM Vitals: - HR: 120 bpm - RR: 30 breaths per minute - MM colour: Pink - CRT: 2 seconds - Temperature: 38.5°C - BP: 120/80 mmHg Objective: - Bodyweight: 5 kg - Demeanour: Alert but slightly lethargic - CVS: No significant findings on auscultation. Pulses normal - Resp: No significant findings on auscultation. Normal respiratory rate and character at rest. - Abdo/ALI: No significant findings. Comfortable on abdominal palpation - Catheter Site: No significant findings. Catheter patent - Hydration: No significant findings. No evidence of hypovolaemia or dehydration Diagnostics: - Blood work: Elevated liver enzymes - X-ray: No abnormalities detected Assessment: - Mild dehydration and possible gastrointestinal upset Treatment: - Administered IV fluids - Prescribed antiemetic medication Plan: - Continue IV fluids for 24 hours - Monitor vitals every 4 hours - Reassess in the morning - Follow-up blood work in 48 hours