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