Writing vet tech notes as a UK veterinary nurse

Vet tech notes are the clinical notes the nursing team writes as it cares for patients, from the hospital sheet on the ward to the anaesthetic chart in theatre. In the UK that work belongs to veterinary nurses, so this guide uses the UK terms and explains where they differ from the American ones. It covers which notes nurses write and what a useful entry in each one contains. The later sections deal with writing habits that save time on a busy shift, and with keeping the vet's notes and the nurse's notes in one record.

Vet techs and veterinary nurses in the UK

"Vet tech" is short for veterinary technician, the title used in the United States for the trained member of the practice team who nurses patients and supports the vet in theatre. The UK equivalent is the veterinary nurse. Where this page says nurse, read vet tech if that is the term you searched for.

The Code of Professional Conduct for Veterinary Nurses, published by the Royal College of Veterinary Surgeons (RCVS), says that only those appropriately registered with the RCVS have the right to practise veterinary nursing in the UK, and that veterinary nurses other than student veterinary nurses must be entered in the Register of Veterinary Nurses. On records, the Code says that veterinary nurses must keep clear, accurate and detailed clinical nursing and client records.

The notes a nursing team writes

Each kind of nursing note below is written for a different reader at a different moment. Knowing who will read a note, and when they will read it, is the quickest way to decide what belongs in it.

Hospitalisation and in-patient monitoring notes

When a patient is admitted, the hospital sheet becomes the running record of its stay. Each observation and each treatment given goes on it with a time, so the vet on the ward round can see at a glance how the day has gone and decide what to change. The next nurse on shift reads the same sheet to find out what is due.

Anaesthetic monitoring records

The nurse monitoring a general anaesthetic records the patient's readings on the anaesthetic chart at the intervals the practice's protocol sets, and notes anything given or anything that happened between readings. The chart is the record of how the patient was from induction until recovery. If a question about the anaesthetic comes up later, the chart is where the vet will look.

Nurse consultations

Nurse clinics are appointments a nurse runs without the vet in the room, such as post-operative checks and weight clinics. The note records what the owner reported and what the nurse found. It then says what was done and what advice the owner took home. If the case needs the vet, the note should say so plainly and name the person who was told.

Handovers

At each change of shift the outgoing nurse hands over the in-patients to the nurse coming on. A written handover kept with each patient's record gives the incoming nurse something to check against when the ward gets busy, so nothing important depends on someone remembering a conversation.

Discharge notes

When a nurse runs the discharge appointment, the record should show what the owner was told and what they took home in writing. If the owner rings with a question a few days later, whoever answers the phone can see exactly what was said.

What a useful nursing entry contains

Whichever note you are writing, each entry should carry the following, so that someone who was not there can understand what happened and act on it.

• The date and the time of the observation or task, written when it happened.
• The name or initials of the person who made the entry.
• What was observed, as a measurement or a plain description of what you saw.
• Each treatment or medication given, recorded exactly as it was given and against the vet's instructions.
• Any change in the patient since the last entry, and who was told about it.
• What is due next, and when it is due.

On a hospital sheet those entries build into a timeline that the vet can scan on the ward round. An anaesthetic chart already gives most of them a column of their own. A handover note needs fewer of them, and it works best when it leads with the patients that need something in the next hour or two.

The RCVS supporting guidance on clinical and client records applies to veterinary nurses as well as veterinary surgeons, and says both must keep clear, accurate and adequately detailed records. According to that guidance, a clinical record should give a complete and relevant account of the animal's clinical history, sufficient to support continuity of care, including the examinations carried out, treatments given, test results, planned investigations, the staff who provided care and the advice given to the client. The guidance also asks for records that are objective and factual, entered at the time or as soon as reasonably practicable afterwards. Where an entry has to be corrected, it says the amendment should leave the original entry readable and show when and by whom it was made.

Habits that make nursing notes clearer and quicker

• Write each entry when the observation is made or the treatment is given. Notes written up at the end of a shift depend on memory, and their times drift towards the moment you sat down to write.
• Describe what you observed in words another person would record the same way. An entry such as "ate half the food offered, standing in the kennel" gives the vet more to go on than "doing well".
• Use only the abbreviations the practice has agreed, and keep that list where everyone can find it. A shortcut one nurse uses every day can be misread by a locum who has never seen it.
• Give every handover the same order, so the incoming nurse always knows where to look for what is due next. A short template agreed by the team does this well, and the handover itself belongs in the patient's record.
• Write in the patient's own record wherever you can, so that nobody has to copy a separate sheet across later.

One record for the vet and the nurse

A patient in the hospital collects notes from several people in a single day. The vet writes the consultation and the treatment plan, and the nurses add what they observed and what they gave through the day and night.

When a paper hospital sheet hangs on the kennel door and the clinical record lives in the practice management system, someone has to retype the sheet before the patient goes home, and every copy is a chance for a time or a dose to change on the way. Handover details passed on only by word of mouth go missing in the same way, and the vet reading the record the next morning sees part of the picture.

Keeping vet and nurse entries in one record for each patient removes the copying and gives everyone the same version of events. Our guide to common mistakes in vet record keeping covers the wider problems that follow when records are incomplete or scattered.

How Vetz supports the nursing team

Vetz is an AI scribe for veterinary practices, designed to be straightforward for nurses and administrators as well as for vets. Its real-time collaboration lets several people work in the same note at the same time. A nurse can add observations to a patient's note while the vet is writing the plan, and each of them sees the other's changes as they happen. Comments sit in the note itself, so a question about an entry is asked right where the entry is.

With smart dictation you speak the note instead of typing it, and Vetz transcribes and structures what you said. During a conversation with an owner, such as a nurse consultation, Vetz listens and produces a structured draft of the clinical note, and it copes with conversations where more than one person is speaking. It runs in the browser or in the iPhone and Android apps, on most devices that have a microphone.

Vetz mirrors the practice's own templates, so a note comes out in the structure your team already uses, and the Vetz team helps a practice set up templates tailored to its routines.

Ask the Vetz team whether your hospital sheets and anaesthetic charts can be set up as practice templates in the same way, so that ward and theatre notes keep the format your nurses already use.

When the note is finished, Vetz transfers it to the practice management system with one click. Its integrations include Provet Cloud and Vettigo. With an active integration, bookings appear in Vetz automatically and the finished note goes back to the practice management system without anyone retyping it. After a discharge appointment, Vetz can also generate discharge advice for the owner straight from the note. The full list is on the Vetz features page, and our guide to AI note-taking for vets explains how the scribe works in a vet's consultation.

Before an AI-drafted note goes in the record

Every draft Vetz writes is read by the nurse or vet before it is approved and transferred to the practice management system. You can correct a draft by hand or ask Vetz to rephrase or clarify a passage, and the person approving the note decides what goes into the record. Vetz recommends telling owners that AI supports the note-taking, and can provide a ready-made wording for the practice to use.

Before any AI tool writes nursing records, put these questions to the vendor.

• Where are recordings and notes stored, and in which country?
• Which subprocessors handle the practice's data?
• How long are recordings and drafts kept, and can the practice set that period itself?
• Who at the vendor can access a practice's records, and in what circumstances?
• How does the practice delete a recording or a note when it needs to?

More about Vetz

If your nursing team spends part of every shift copying hospital sheets into the practice management system, book a demo and we will show you how vets and nurses can work in one shared note in Vetz.