AI Note-Taking for Vets and AI-Assisted Medical Record Keeping

The search term “AI note-taking for vets” typically refers to tools that track the conversation during a veterinary visit and convert relevant information into a structured draft medical record. The practitioner then reviews and edits the draft. The medical record entry is approved before it is entered into the clinic’s medical record system.

This workflow can reduce manual charting while allowing the clinic to retain its existing charting system. The AI tool serves as a support for charting, while the clinician retains control over the final chart entry.

How AI Notes Work During a Veterinary Visit

At the start of the visit, the practitioner activates the tool so that the conversation with the pet owner can be recorded. The AI interprets the information as the consultation proceeds and uses the clinic’s selected medical record template. After the conversation, a draft is created using the structure the clinic has configured.

A typical workflow includes the following steps.

1. The therapist starts the recording when the consultation begins.
2. The tool identifies relevant information from the conversation.
3. The information is organized according to the clinic's medical record template and procedures.
4. A draft medical record is created after the consultation.
5. The editor reviews the content and makes any necessary changes.
6. The completed note is approved and can be transferred to the medical records system.

AI-generated drafts always require medical review. Names, findings, phrasing, and other information may need to be corrected or supplemented before the medical record is approved.

How Vetz Works in Practice

Vetz listens during the conversation with the pet owner and interprets the information in real time. The tool uses the clinic’s templates to create a structured draft of the medical record. The practitioner can then review the text and make adjustments before signing it.

Once active integration is in place, the completed medical record can be transferred to the medical record system. A more detailed overview is available in the guide titled “How Vetz Works: From Patient Appointment to Completed Medical Record.”

Clinicians who prefer to record a note can also use AI dictation for veterinarians. Vetz then transcribes the dictated text and formats it as a medical record entry. The AI medical record-keeping page contains more information on how to use the tool in daily medical record-keeping.

Support for additional aspects of medical record-keeping

In addition to the draft medical record itself, Vetz can assist with several related tasks. The suggestions are based on the content of the medical record and must be reviewed by the treating physician before they are used.

• Medical phrasing can be reworded or clarified to fit the language and structure of the medical record.
• Relevant diagnosis codes can be suggested based on the note.
• Personalized discharge instructions can be generated from the medical record.
• The need for a follow-up visit or other follow-up can be noted.
• Billing proposals can be prepared based on the information in the medical record.
• Existing text can be edited manually or processed using AI.

These recommendations do not replace the clinician’s assessment. Diagnosis codes, discharge instructions, and billing documentation must be verified as part of the overall medical record review.

Custom medical record templates and collaborative work

The clinic can map its own medical record templates to Vetz. This makes it possible to build on existing headings and local procedures rather than implementing an entirely new medical record structure.

During the evaluation, the clinic should test the templates using the types of visits that actually occur in its operations. A routine visit may place different demands on the structure than an emergency visit or a phone call. The test should also demonstrate how required information and clinic-specific wording are handled.

Multiple team members can work on the same medical record in Vetz. They can comment on and edit the content, as well as view updates in real time. Before implementation, the clinic should determine who is authorized to edit a draft and who approves the final entry.

Equipment and Methods of Use

Vetz is accessed through a web browser and does not require installation on your computer. The platform is also available as an app for iPhone and Android.

A computer or cell phone with a microphone can be used during the consultation. The tool also works on a tablet with a microphone. No specific external microphone is required.

Vetz can handle calls with multiple participants. This makes the tool useful when both the veterinarian and the pet owner are participating in the call. The platform can also be used for video and phone consultations.

The clinic should test the audio recording in the rooms and with the devices that will be used. Otherwise, background noise and the placement of the device may affect how well the conversation is captured.

Vetz recommends that the animal owner be informed that AI is used to support the record. The clinic should establish a standard wording and determine when the information should be provided.

Integration with the existing medical records system

A separate AI writing tool does not necessarily mean that the clinic has to switch medical record systems. Vetz integrates with Provet Cloud and Vettigo. MHK FileMaker is also listed as a supported integration.

Once the integration is active, appointments are automatically displayed in Vetz. After review, the completed medical record can be transferred back to the medical record system, reducing the need for manual data entry.

Clinics that use a different system should request a review of the possible integration setup. It must be clear whether the transfer takes place directly via an API or through the medical record system’s export and import functions. The clinic should also verify which medical record fields can be filled in and how the correct patient is linked to the correct note.

Learn more about Vetz's integration with medical record systems and how AI support can be used in conjunction with an existing medical record system for veterinarians.

Medical Review of AI Drafts

Even a well-structured draft may still contain errors or omit information that was not clearly stated during the visit. The practitioner must therefore verify that the medical record entry accurately reflects the consultation before approving it.

An article in the Swedish Veterinary Journal about a pilot project with Vetnio describes how the veterinarian reviewed the notes after each consultation and adjusted them as needed. In this particular pilot project, the tool was not integrated with the medical record system. The text was therefore copied manually into the medical record.

This example illustrates two issues that should be evaluated separately. One concerns the quality of the generated draft. The other concerns how the note is transferred to the clinic’s medical record system. A demonstration should show both steps using the clinic’s own workflows.

Purchasing Checklist for AI Writing Tools

A clinic evaluating AI note-taking for veterinarians should ask the provider to demonstrate how the tool works during an actual patient visit. A prepared sample text does not provide the same basis for evaluation as a walkthrough from the start of the recording to the approved medical record.

Include the following questions in the evaluation.

1. Can the provider demonstrate the entire process, from consultation to a reviewed and approved medical record?
2. Can the clinic's own medical record templates be tested using actual visit types?
3. How are multiple patients or multiple animals discussed during the same consultation handled?
4. Which parts of the transfer to the medical records system are automated?
5. Where are audio recordings, drafts, and final journal entries stored?
6. Which subcontractors process the clinic's data?
7. How are user permissions and access controlled?
8. How long are audio recordings and other data retained, and how does the clinic request their deletion?
9. What support and training are included with the implementation?
10. How are service disruptions and logging handled when the service is unavailable?

Information about Vetz’s security measures is available on the page about security and data protection. The clinic should then direct any operation-specific questions to the vendor and document the responses before making its decision.

More detailed guidance is available in the guide on choosing an AI scribe for a veterinary clinic.

Compare workflows at the category level

AI writing tools for veterinarians may differ in terms of templates and integrations. The methods used for review, access control, and storage may also vary. The comparison should therefore be based on the clinic’s actual patient visits and medical record system.

Check current offers directly on co.vet, vetnio.com, digitail.com, scribblevet.com, and vetrec.io before comparing vendors. Ask each vendor to demonstrate the same test cases and answer the same purchasing questions. This will make it easier to assess how each tool fits into your clinic’s workflow.

Learn more about Vetz

See how the conversation is converted into a draft medical record that can be reviewed, and how the data transfer can work with the clinic’s existing medical record system. Schedule a demo of Vetz focused on AI notes and medical record-keeping.