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Current Health Status, History

Summary:

The intention of this section is to provide veterinary technicians with guidelines for writing the patient care plan portion of the veterinary medical record. As there is no standardized format for writing a veterinary care plan, the following principles are only one example of how a care plan may be formulated.

Objective

  • To obtain further information about the current health status of patient from the client, which may or may not be related to the primary complaint.

What to Include

Tailor this information to the species of the patient.

  • Other current medical or surgical conditions
  • Allergies
  • Diet/appetite/water intake:
    • Who feeds and waters?
    • Brand and type of food
    • Amount and frequency of food
    • Feeding patterns and procedures
    • Types of feeders/”waterers” (communal or individual)
    • Water source
    • Temperature and amount of water
    • Other water intake opportunities (puddles, ponds etc.)
    • Changes
  • Bowel movements/urination: Amount, frequency, color, consistency, odor, changes
  • Exercise: Amount, frequency, when, type, changes
  • Current medications: What, why, type, dose, frequency, form, results, reactions, Rx (by whom), over the counter (include: anthelmintics, preventative, supplements, vitamins, etc.)
  • Husbandry/care/sanitation/grooming management: What, who, when, how often?
  • Tests: Clinical and diagnostic laboratory, imaging, etc.
  • Vaccinations: Date, disease, type, brand, serial number, route of administration, etc.
  • Geographical history
    • Travel: Means of transportation, where, when, duration, why (ex. vacation, fair, show, training, breeding, boarding, etc.), contact with other animals
    • Geographic origin: Location (ex. humane shelter, neighboring farm, auction, pet shop, home farm raised, etc.)
    • Prior “ownership”: Who, where
    • Client or other human, animal, or other contacts from off or on the premises: (ex. Client was in a foreign country, visitor from another farm, visit to clinic, use of neighbor’s equipment, contact with wildlife or other domestic animals, ticks, mosquitoes, flies or other insects etc.)
  • Environmental history:
    • Indoor, outdoor, or both
    • Tethered, free-roaming, fenced
    • Type of housing
    • Shade and protection from weather
    • Access to trash, chemicals, old painted surfaces (lead)
    • Water sources
    • Weather
    • Wetlands
    • Pasture type
  • “Family” history:
    • Genetic defects
    • Infectious diseases (patient’s “littermates”)
    • Changes in or additions to other animals residing at same location
    • Changes and possible related health problems in human client family structure.
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Copyright ©1995-2018 by The Writing Lab & The OWL at Purdue and Purdue University. All rights reserved. This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission. Use of this site constitutes acceptance of our terms and conditions of fair use.