AES OUTPATIENT

HISTORY: [Detail the patients presenting complaint] (Do not use bullet points unless explicitly mentioned in the transcript, contextual notes, or clinical note) - Current meds: [List current medications patient is taking] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Prophylaxis: [Describe any prophylactic treatments patient is receiving] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Pre-existing conditions: [List any pre-existing medical conditions of the patient] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Access to toxins eg. Rodenticide: [Indicate whether there has been access to toxins] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) TRIAGE: - HR: [Heart rate in beats per minute] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - RR: [Respiratory rate in breaths per minute] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Temp: [Temperature in degrees Celsius or Fahrenheit] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Mm: [Mucous membrane assessment findings] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Crt: [Capillary refill time assessment findings] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Mentation: [Description of the patient's mental status and alertness level] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Pain Scale (0-4): [Pain score with a scale from 0 (no pain) to 4 (severe pain)] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) - Hydration status (%): [Estimated percentage of dehydration] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) EXAMINATION: [Subheadings for each system examined with generic descriptors for normal findings or areas assessed] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) PROBLEM LIST: [List identified problems during history taking and examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) DIFFERENTIAL DIAGNOSIS/ DIAGNOSIS: [List possible differential diagnoses or confirmed diagnosis based on clinical findings] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) DIAGNOSTIC/MANAGEMENT PLAN: [Outline proposed diagnostic tests and management plan for the patient's condition(s)] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) DIAGNOSTICS: [Details of diagnostic tests performed or recommended, including lab work, imaging, etc.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) ASSESSMENT: [Clinician's assessment based on history, triage, examination, and diagnostics results] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) TREATMENT: [Details of treatments administered during the consultation including dosages and routes if applicable] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) PLAN: [Outline follow-up care plan including further testing, treatment adjustments, etc.] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) CLIENT COMMUNICATION: [Summary of information communicated to client regarding their pet’s condition and care instructions] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) CLIENT DISCHARGE NOTES PRESENTING CONCERNS: [Detail the patient’s presenting complaint] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) PROBLEM LIST FROM PHYSICAL EXAMINATION AND HISTORY: [List identified problems during history taking and examination] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) ASSESSMENT: [Clinician's assessment based on history, triage, examination, and diagnostics results] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) PLAN/DISCUSSION: [Outline proposed diagnostic tests and management plan for the patient's condition(s)] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) TREATMENTS ADMINISTERED: [Details of treatments administered during the consultation including dosages and routes if applicable] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) Medications for Administration at Home: [List medications prescribed for home administration] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) SPECIFIC HOME CARE INSTRUCTIONS: [Provide detailed instructions for care at home] (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank) The Animal Emergency Service advises a reassessment with your regular vet within 48 hours to monitor your pet's progress. If your pet's condition deteriorates or they become flat or lethargic, go off their food and water, develop vomiting or diarrhoea, or if you have any concerns please contact the Animal Emergency Service or your regular vet immediately. If your pet is going home and has a pressure wrap over where an IV catheter was placed, please remove it within 20 minutes of leaving the hospital. Thank you for trusting the Animal Emergency Service with the care of your pet.