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Past, Birth, and Referral 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.

Note: Many aspects of the current complaint history and status and past, birth, and referral history may be interrelated and overlap.

Objective

  • To obtain information about the past, birth, and referral history of patient from the client.

What to Include

Past history:

  • Medical
  • Treatments and responses
  • Surgical (including neutering, tail docking, ear cropping etc.)
  • Trauma
  • Vaccination/immunizations
  • Diagnostic tests
  • Medications
  • Weight history
  • Geographic history (travel) and origin
  • Environmental
  • Previous diet

Birth history: Where, when, complications, littermates (number and health status, if known), etc.

Referral history: Including referral practice

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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 This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission.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.