This section is intended 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. These principles have been adapted from materials developed by veterinary technology instructor/academic advisor Jamelyn Schoenbeck Walsh and veterinary instructional technologist Margaret Lump of Purdue University’s Veterinary Technology Program.

Veterinary medical records must be complete, accurate, orderly, and legible and should give a description of what was done, when, by whom, why, how, and where. Because they are legal documents, certain conventions must be followed when recording information. Of concern are legal issues surrounding documentation.

A patient’s record is a compilation of all written information, reports, and communication regarding the patient’s care, and it should render a full understanding of the patient’s health status. To this end, a patient care plan should include, but is not limited to, the following parts:

• Patient signalment and client information
• History and presenting chief complaint
• Current health status and history
• Past, birth, and referral history
• Patient assessment
• Technician evaluation
• Interventions
• Rationale for interventions
• Continued patient reassessment
• Desired resolutions
• Progress notes
• Discharge planning
• Legal issues of documentation
• Sample care plan example

Each of the sections above contains guidelines on what information to include and how, as well as relevant examples of how a specific case might be documented.

A complete sample patient care plan will be available soon. Please note this PDF is a sample and should not be used as a template. For formatting questions, consult your instructor.