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Patient Signalment, Client Information

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.

Objectives

  • To collect, classify, and record required patient information.
  • To identify the relevance and interrelationship of the information as it relates to:
    • Diagnosis
    • Treatment
    • Nursing care
    • Patient progress

What to Include

Date and time of admittance: Establishes a starting point for intervention and monitoring

Signalment: Assists with proper identification of the patient, diagnosis, and predilections to traits and conditions as some conditions may be species, breed, gender, age, and color specific. Note: Most signalment information does not change over time. Exceptions to this include acquired markings, age, reproductive status, and means of identification.

Patient identification: Name, number, electronic ID

Species

Breed

Gender and reproductive status

Age: In years, months, weeks, or days depending on age of patient

Color: In order of predominance

Distinctive markings: Genetic and acquired (including tattoos, ear notches and cropping, scars, tail docking, etc.)

Client information, including:

  • Client name
  • Contact information: Patient address also provides geographical history of patient which may help in assessment. Include a second party emergency contact.
  • Co-owner information: Important for treatment and euthanasia decisions
  • Referring veterinarian if applicable
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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 This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission.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.