Veterinarian Template

SOAP Note (Veterinary Hospitalisation)

A professional Veterinarian template for healthcare professionals.

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Specialty

Veterinarian

Used

56 times

Type

Note

Last edited

9/9/2024

Created by

Shan Li

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About this template

This Veterinary Hospitalisation SOAP Note template is designed for veterinarians working in emergency settings. It provides a structured format to document patient evaluations, including vital signs, diagnostic tests, and treatment plans. This template is ideal for capturing comprehensive clinical information during hospitalisation, ensuring continuity of care. Veterinarians can use this template to efficiently record and communicate patient status and treatment interventions, enhancing the quality of care provided. The template is optimized for use with AI medical scribe software like Heidi, streamlining the documentation process in busy veterinary practices.

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Reason: Bella, a 5-year-old Labrador Retriever, was referred for evaluation due to persistent vomiting and lethargy over the past 48 hours. The owner reported that Bella had ingested a foreign object during a walk. Time: 14:30 Objective: - Bodyweight: 30 kg - Demeanour: Alert but slightly lethargic - TPR: - HR: 110 beats per minute - RR: 24 per minute - MM Colour: Pink - CRT: 1.5 seconds - Temp: 38.5°C - Blood pressure: 120/80 mmHg - CVS: No significant findings on auscultation. Pulses normal - Resp: No significant findings on auscultation. Normal respiratory rate and character at rest. - Abdo/ALI: Mild discomfort on abdominal palpation, possible foreign body palpable - Catheter Site: No significant findings. Catheter patent - Hydration: Mild dehydration noted Diagnostics: - Abdominal X-ray: Foreign object detected in the stomach - Bloodwork: Elevated white blood cell count Assessment: Bella is experiencing gastrointestinal distress likely due to the ingestion of a foreign object. The presence of the object in the stomach is causing vomiting and mild dehydration. Treatment: - Administered IV fluids to address dehydration - Initiated antiemetic therapy - Scheduled for endoscopic retrieval of the foreign object - Refer to flowsheet for full treatment plan Plan: - Continue hospitalisation until fit for discharge - Monitor hydration status and adjust fluid therapy as needed - Re-evaluate post-endoscopy for any complications