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History, Presenting Chief Complaint

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 a detailed chronological narrative of events from the client
  • To record all actions, events and/or behaviors of the patient leading up to the current injury or illness.

What to Do

When obtaining information from a client, keep in mind the followign guidelines:

Direct the flow of conversation by requesting rather than suggesting answers. Ensure that you are not putting words into a client’s mouth or biasing the client’s answers.

  • Ask open-ended questions
  • Record the information in the client’s own words

Follow up with qualifying questions about the first problem before moving on to a new problem.

After taking the history (1) use reflective listening and confirm information by paraphrasing important points, and (2) record information in patient record.

Things to Remember

Remember that the client and veterinary health care team will have similar but not identical concerns.

  • The client will be concerned with probability of recovery with/without treatment, complete vs. partial recovery, and nature and cost of treatment.
  • The veterinary health care team will be concerned with obtaining meaningful information about patient’s medical history to assist in the development of a definitive diagnosis and appropriate treatment plan.

Distinguish between client observations (facts) and interpretations of observations.

Example: “The client saw the calf licking its side”not “The client said the calf was in pain because they saw it licking its side.”

Determine if the information the client provides is first or second hand.

No information is better than the wrong information

Note: Collecting a patient history is both a science (asking the right questions), and an art (asking them in the right way).

What to Include

Onset of the current problem

"The last time Fido ate without vomiting was two days ago."

Anatomical location of the problem or body system affected

"Fido’s stomach grumbles prior to vomiting.

Character of the problem, including:

  • Quality
    "The vomit contained whole food and watery fluid."
  • Severity
    "Fido has violent retching followed by projectile vomiting."
  • Onset
    "The vomiting started yesterday morning."
  • Duration
    "Fido has been vomiting for about a week."
  • Time of day
    "Fido vomits mostly in the morning."
  • Frequency
    "Fido vomits multiple times a day."
  • Triggers (influences related to the occurrence of the problem):
    • Setting
      "Fido vomits shortly after eating."
    • Factors that increase signs
      "Fido vomits when she rapidly eats a lot of food."
    • Factors that decrease signs
      "Fido doesn’t vomit when I feed her small amounts of food divided over several hours."
    • Associated problems
      "Fido also has diarrhea occasionally."
    • Progression
      "Fido seems to be vomiting more frequently."
    • Improvement
      "I haven’t noticed her vomiting today."

    *Parts adapted from Osborne, C.A. (2001). The Medical History: Are you asking questions right?. DVM, 32, 21.

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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.