How to write a complete medical note

Medical Records can save our licenses but also consume our time. They are legal documents that must be completed within a reasonable time, which can vary by state law. When we see multiple appointments in the clinic, we can sometimes become lax on our medical records, often forgetting some of the most important information. The issue is if it is not documented, then it never happened. If it never happened, according to the record, it would be very difficult to defend yourself or know what care the patient received during follow-up care.

The big question: how much information and what needs to be in the record? Every state has different guidelines you should follow, but here are some themes to ensure your records are as complete as possible.

Vitals

Vital signs are crucial in documenting an animal’s health status within medical records. At minimum, weight, temperature, pulse, and respiration should be documented. Capillary refill time (CRT), body condition score (BCS), pain assessment, and muscle condition should also be recorded for completeness. State regulations may mandate the documentation of reasons for unrecorded vital signs, emphasizing the importance of comprehensive medical records.

Subjective

Capturing the owner’s insights within the “Subjective” section is crucial for a comprehensive understanding of the animal’s health history. This information often plays a pivotal role in shaping assessment, diagnostics, and treatment plans.

Information typically gets dripped throughout the appointment. For instance, the fact that the patient ingested a sock three days prior might only be mentioned as the client is walking out the door. Always revisit your subjective at the end of each appointment to document this information.

Primary Complaint

For completeness of the Subjective, it should include the clinical signs, the primary complaint with the duration of clinical signs, and any history surrounding this concern.

Previous Medical History

This should include any previous medical history that is important to this pet.

Medication/Supplement

All medications the patient receives should be documented, including dosages. This includes heartworm prevention, nutraceuticals and other over-the-counter medications, and prescription medication.

When treating a pet, we must remember to assess and address the potential for medication interactions. Including current medications helps keep this at the forefront of your mind and establish in writing what information you are privy to.

Diet and Nutrition

Diet and nutrition play a significant role in an animal’s health. If the pet is on a grain-free diet and you find a heart murmur, this should help steer your conversation. Without that information, you miss an opportunity to provide the client with professional knowledge and recommendations instead of what they find online.

Lifestyle and Environment

Getting more information on where the pet lives and what other animals they are exposed to will help guide vaccination recommendations, preventatives, and other discussions.

By including these elements in the subjective portion of the medical record, all the information is in one place. This information serves as the foundation for the diagnostic and treatment process, guiding you in formulating an accurate assessment and developing an appropriate plan of care tailored to the animal’s individual needs.

Objective

In veterinary medicine, the objective component of a medical record is crucial because it provides a standardized, factual assessment of the animal’s physical examination findings. It can also provide diagnostic test results and other measurable data. The objective portion of the medical record is based on direct observations made by the veterinarian during the examination or diagnostic procedures.

Physical Examination Findings

Each body system should be documented with descriptors for both normal and abnormal findings. Normal findings should always be recorded to document what was assessed on the pet during the physical examination.

• Body Condition Score: Assess the animal’s body condition using a standardized scoring system to evaluate weight and body condition.
• General Appearance: Describe the animal’s overall demeanor, posture, and level of alertness.
• Skin and Coat: Note any abnormalities such as lesions, rashes, alopecia, or signs of inflammation.
• Eyes: Document observations related to eye health, including discharge, redness, cloudiness, or abnormalities in pupil size or shape.
• Ears: Describe the appearance of the ears and note any signs of inflammation, discharge, odor, or ear canal abnormalities.
• Mouth and Teeth: Evaluate the condition of the oral cavity, teeth, and gums, noting any abnormalities such as tartar buildup, gingivitis, or oral lesions.
• Respiratory System: Auscultate lung sounds and assess respiratory effort, noting any abnormalities such as coughing, wheezing, or dyspnea.
• Cardiovascular System: Auscultate heart sounds and assess heart rate, rhythm, and pulse quality.
• Gastrointestinal System: Palpate the abdomen and assess for organomegaly, masses, fluid, or abdominal pain.
• Musculoskeletal System: Evaluate gait, joint range of motion, and muscle tone, noting any signs of lameness, stiffness, or discomfort.

Diagnostic Test Results

Some veterinarians will put the diagnostics and test results in the Objective. In contrast, some will put this portion in the Plan. Either way, this should include bloodwork, urinalysis, imaging, cytology, etc. The results of all diagnostics should also be documented unless they are pending, in which case they should be noted.

By including these elements in the objective portion of the medical record, veterinarians can provide a detailed, accurate, and standardized assessment of the animal’s physical status and diagnostic findings. This information is a basis for formulating a diagnosis, developing a treatment plan, and monitoring the animal’s response to therapy over time. Additionally, objective documentation facilitates communication among veterinary team members, enhances continuity of care, and ensures accountability in veterinary practice.

Assessment

The Assessment portion represents the abnormal information gathered in the Subjective and Objective. Each problem/abnormal should trigger a differential diagnosis list and potentially a definitive diagnosis, if reached.

This section is a great addition to the medical record as a concise summary of what is wrong with the pet.

Plan

This Plan is essential because it outlines the specific details of the treatment plan, follow-up, and client communication. This serves as a roadmap for implementing the veterinarian’s recommendations and will help guide the ongoing management of the pet’s condition.

Treatment Protocol

In this section, the veterinarian should list everything completed during the appointment and the protocol they would like to follow to aid in the pet’s care. This also provides a point of comparison from a liability standpoint in what you requested as an acting veterinarian and the treatments administered by other individuals.

Medications/Vaccinations Administered

Any medication administered in the hospital should be documented. Not just that it was administered, but the dose, route, concentration (if applicable), and how often.

The vaccinations should always be included with the route, duration, and location. One reason for this is if the pet comes back and has a local reaction, you can determine which vaccination may have caused it.

Medications Prescribed

Many electronic medical records will list the medications to go home in them under their orders or another section. The concern comes when that order is incorrect. By documenting this in detail (strength, dosing interval, method of administration, duration, quantity, and refills) in your medical record, if there are any concerns, they will automatically go back to your medical record and see the correct dosing.

Recommendations and Discussion

All medical recommendations and discussions with the client should be documented in the Plan. Remember, if it wasn’t documented, it never happened.

Declined Items

While we all recommend gold-standard medicine, sometimes clients decline things. Documentation of the discussion and that the client declined will show that you were, in fact, recommending what was needed.

Home Care Instructions/Handouts

When recommending treatments for the owner to carry out after discharge, putting in the home care instructions is imperative. Often, clients are not always listening or find themselves overwhelmed by the information and will call back after. By documenting this, the staff can review the medical record and give the client the information.

Follow-up

You should be documenting what the follow-up would be in each case. Suppose you are not the next veterinarian or person to pick up that record. In that case, they can still follow the care you instructed.

Medical records are legal documents that show what was discussed with the client, physical examination findings, your assessment, treatments, and next steps. Medical records may be used for clinical or even legal purposes, so while they may not be the most fulfilling part of your day, it is essential to ensure they are complete.