How to write and manage veterinary discharge instructions

Discharge instructions are what the owner takes home after a procedure or a hospital stay. For many owners they are the only part of the visit they read again, at home and with nobody from the practice there to explain a line they do not understand. The sheet has to make sense on its own, and it has to agree with what the clinical record says was done and dispensed.

What veterinary discharge instructions should include

Good instructions answer the questions an owner would otherwise ring the practice to ask. Most sheets need the following, adapted to the patient and the procedure:

• Each medication by name, with the dose and the times of day to give it.
• Wound or dressing care, including how the site should look and when the dressing comes off.
• Feeding instructions for the first days at home, with any change of diet spelled out.
• Exercise limits in concrete terms, for example how long lead walks may last and when that changes.
• The warning signs that mean the owner should call the practice straight away.
• The date and time of the follow-up appointment, or when the owner should book one.
• The practice's phone number, with the number to use out of hours.

Anything particular to the case belongs on the sheet as well, such as a buster collar the patient has to keep on or a sample the owner is asked to bring to the recheck.

Why discharge notes go wrong in a busy clinic

Most of the trouble starts with when the sheet gets written. The vet is often finishing it while the next client waits, so the quickest route is to open the sheet from a similar case and edit it. A copied template can carry over details that belonged to another patient, such as a different dose or a dressing this patient never had.

Instructions written apart from the clinical notes also drift away from them over time, until the sheet says one thing and the record another. Clinical shorthand that reads well in the notes means little to an owner at home. When no copy is filed, the practice cannot show what the owner was told if a question comes up weeks later.

Several of these faults are the same ones that turn up in clinical records generally, which are covered in common mistakes in vet record keeping.

The simplest way to manage discharge notes

In the simplest workflow every sheet starts from the clinical record, so nothing on it has to be remembered or retyped, and the steps run in this order:

1. Write the clinical notes first, so the record holds what was done and what was dispensed.
2. Keep one template per common case, such as a routine neutering or a dental, and update the templates when the practice's protocols change.
3. Build each sheet from that day's notes and the matching template, never from the last similar sheet.
4. Have a vet or nurse check the sheet against the record before it reaches the owner, with most attention on the medication section.
5. Go through the sheet with the owner at discharge and give them a copy to keep.
6. Save the version the owner received to the patient's clinical record.

A practice can run this with templates in its practice management system and a checking habit at the discharge desk. The step that takes the most time is writing each individual sheet, and that is the step Vetz takes on.

How Vetz writes discharge instructions from the consultation note

Vetz listens during the consultation and writes a structured draft of the clinical notes, using the practice's own note templates. From those notes, its AI assistant generates individual discharge advice for the owner, written to be clear and easy to understand without extra work from the vet. Because the advice comes from the same notes that go into the record, it starts from what the vet recorded for this patient instead of from an older sheet.

The vet reads the draft and can edit it by hand or ask Vetz to improve or rephrase a passage before anything is handed over. Vetz is built as a support for the vet, who stays in control of the note and of what the owner takes home. How the scribe captures the consultation itself is covered in more detail in the guide to AI note taking for vets.

How the rest of the workflow feeds the discharge sheet

Discharge advice draws on the whole consultation note, so the parts of Vetz around it matter too. The AI scribe writes into the practice's own templates, which keeps the findings and the plan in the same structure from one case to the next. Vetz can also remind the vet about a return visit or follow-up, and its calendar keeps track of appointments and rechecks, so the sheet has a follow-up to point the owner to.

Provet Cloud is one of the practice management systems Vetz integrates with. Bookings appear in Vetz automatically, and when the note is finished it can be transferred straight back into the practice management system without anyone typing it twice. For a system that is not yet supported, the article on how Vetz integrates with your practice management system explains how the connection works through APIs or export and import functions.

Writing instructions an owner can follow

The owner reading a discharge sheet has no veterinary training and may be anxious about the animal, so the language that works in clinical notes needs translating. Swap abbreviations and Latin terms for everyday words, and break the care into short steps in the order the owner will carry them out.

Dates and times should be written out in full. "Recheck on Tuesday 17 November" leaves far less room for doubt than "recheck in ten days", and the same goes for the time of each dose. Before the sheet goes out, check every medication line against what was actually dispensed, including the strength printed on the label. Vetz writes its discharge advice in plain language, but the check against the dispensing record stays with the person who signs the sheet off.

What the RCVS says about clinical records and client communication

The RCVS supporting guidance on clinical and client records says that veterinary surgeons and veterinary nurses must keep clear, accurate and adequately detailed records. It expects clinical records to give a complete and relevant account of the animal's history, including the advice given, and to be entered contemporaneously or as soon as reasonably practicable after the event. The same guidance says that copies of relevant clinical records must be provided when a client asks for them. Filing the discharge sheet with the clinical notes keeps the advice the owner took home inside that account.

The RCVS guidance on communication and consent asks vets and nurses to use language appropriate for the client and to explain any clinical or technical terminology. It also asks them to make sure that what is said is heard and understood on both sides, for example by asking questions and summarising the main points of the discussion. In its section on consent, the guidance notes that information leaflets can explain the expected outcome and aftercare, and adds that leaflets should not be used as a substitute for discussion with the individual client.

Questions to ask before software drafts client-facing instructions

Any tool that writes text an owner will act on deserves some questions before it goes live in the practice. These are worth putting to every vendor, Vetz included:

• Where are recordings and notes stored, and in which country?
• Which subprocessors handle the practice's data?
• Can the practice require a vet or nurse to approve every sheet before an owner sees it?
• Are edits to generated instructions logged, and can the practice see who changed what?
• Is the discharge advice saved to the patient's record along with the clinical notes?
• How long are recordings and drafts kept, and how are they deleted?

The Vetz security page is a place to start, and the Vetz team can answer the rest directly. On consent, Vetz recommends telling owners that AI supports the note-taking, and it can provide ready wording for the practice to use.

More about Vetz

If writing discharge instructions takes up time at the end of every consultation, book a demo and we will show you how Vetz turns the consultation note into discharge advice your team can check and hand over. You can also try Vetz free for 14 days without entering any card details.