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Progress Notes

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 accurately monitor, assess, and record the patient’s progress.
  • To determine whether the patient is achieving the ideal responses and report progress, relapses, or new problems to the veterinarian.
  • To perform technician evaluation and intervention sequence for all new problems.
  • To list all resolved problems and needs.

What to Include

Documentation of all actions and interventions, including:

  • Doses of medication
  • Procedures

Documentation of all patient responses, including:

  • Any observations related to technician evaluations
  • Problems that have been resolved
  • Disease and treatment sequelae (begin new intervention sequence)

Note: All entries should include the date and time of the entry as well as the initials of the veterinary technician.

Example "Progress Notes"

Returning to the case of the mastitis cow, the following are examples of notes that would be included as you monitor and document the patient’s progress.

4:50PM 9/10/05 T 103.5, P 70, R 10, MMC pale, MMM dry, skin turgor: 4+ sec, CRT: 3 sec, udder hot and hard djw

5:15PM 9/10/05 Collected milk samples and set up culture and sensitivity 5:15PM 9/10/05djw

5:30PM 9/10/05 Ketones: 2+ were identified in milk and urine djw

6PM 9/10/05 Milked and striped quarters djw

7PM 9/10/05 Fed, watered, re-bedded stall, groomed, ate ~3 lbs of hay, drank ~1 gallon of water djw
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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 This material may not be published, reproduced, broadcast, rewritten, or redistributed without permission.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.