Veterinary medical records: contents and free templates

A veterinary medical record is the written account of an animal's care at your practice, from the day it is registered to its most recent visit. Whoever sees the patient next relies on it to pick up the case. The practice relies on it too when a client questions a decision or a case is reviewed months later, so a thin record can cause problems long after the consultation has ended.

Below you will find what a complete clinical record contains and how to keep it well, followed by a physical exam template and a medical record template you can copy into your own system.

What a veterinary medical record is for

In UK practice the clinical record is the working document the team treats the animal from. It is also the evidence of what was examined and what the owner agreed to if a decision is questioned later.

The RCVS sets out what it expects in chapter 13 of the supporting guidance to its Code of Professional Conduct, which covers clinical and client records. It says veterinary surgeons and veterinary nurses must keep clear, accurate records with adequate detail. In the guidance, the clinical record should give an account of the animal's clinical history that is sufficient to support continuity of care, covering examinations, treatments given, test results, who provided the care and the advice given to the client.

What a complete record contains

A patient's record grows one entry at a time. Registration sets down the fixed details about the animal and its owner, and every consultation, phone call, test result, procedure and repeat prescription adds a dated entry beneath them. After a few years the record holds the animal's clinical history in order, and a vet who has never met the patient can read it from the top.

A complete record covers these parts:

Patient and owner identification. The animal's name, species, breed, sex and neutering status, date of birth and microchip number, with the owner's name and contact details.
History. The presenting complaint in the owner's words, how long it has been going on, diet, current medication and anything relevant from earlier visits.
Examination findings. Everything found on clinical examination, normal findings included, so a later reader knows each system was checked.
Diagnostics. The tests run and samples taken, with their results once they come back.
Diagnosis or differentials. Your assessment of the problem, with any differentials you are still considering.
Treatment and medicines. Everything given in the practice or supplied to take home, with the dose and quantity.
Consent. What the owner agreed to, including any estimate of cost they were given.
Client communication. Advice given in person or by phone, and any decision the owner made against your advice.
Plan and follow-up. The recheck date and what the owner has been asked to watch for before then.

Many practices write each consultation entry in SOAP order. SOAP is one way to order an entry so that the history comes before the findings and the findings come before the plan, and other layouts work equally well. What helps a vet reading a colleague's note is finding every entry in the practice laid out the same way. For the gaps that most often weaken records, read our article on common mistakes in vet record keeping.

How to keep clinical records day to day

Write each entry during the consultation or straight after it, while the detail is still fresh, and write it so that a colleague who was not in the room can follow it. Every entry should carry the date and the name of the person who made it. Abbreviations are fine when the whole team reads them the same way, and a short practice list of accepted ones saves guessing.

When an entry needs correcting, add a dated correction and leave the original readable. A practice management system can keep that history of changes for you. In a paper or word-processor record it depends on whoever makes the change, which is one reason to keep records inside a system rather than in loose documents.

The same RCVS guidance asks for entries to be objective and factual, and to be made at the time or as soon as reasonably practicable afterwards. It says an amendment should not remove or obscure the original entry. The guidance sets no fixed number of years for keeping records; it says clinical records should be kept for as long as is necessary, taking account of legal and regulatory duties such as the record-keeping rules for veterinary medicines, and notes that a practice's professional indemnity insurer may set a minimum period.

Recording veterinary medicines

Medicines carry record-keeping duties of their own, separate from the clinical note.

In Great Britain, regulation 23 of the Veterinary Medicines Regulations 2013 requires anyone permitted to supply a POM-V or POM-VPS medicine to keep documents for each product they receive or supply. These show the date, the product's name, its pharmaceutical form and strength, the batch number, the quantity, the expiry date and the name and address of the supplier or recipient, along with the prescriber's name and contact details where there is a written prescription. For non-food-producing animals the batch number may instead be recorded on the date the batch is received or first supplied. The regulations require these records to be kept for at least five years.

The record template further down gives medicines their own line in each consultation entry, so these details sit with the rest of the visit.

Data protection and owner access

Clinical records about animals also hold information about people, such as the owner's name, address and phone number, and notes of conversations with them.

The UK GDPR defines personal data as any information relating to an identified or identifiable person, so the owner details held in a clinical record are personal data. Under the UK GDPR an owner can ask the practice for a copy of the personal data it holds about them, and the request is answered free of charge unless it is manifestly unfounded or excessive.

If your records are kept in software, ask the vendor these questions before you sign:

Where is the record data stored, and in which country?
Which subprocessors handle the data, and for what purpose?
How long are records and any consultation recordings kept, and can the practice set that period?
What happens to the practice's data if the contract ends, and in what format can it be exported?
Who at the vendor can see clinical notes, and in what circumstances?

Vetz sets out how it handles data on its security page.

Veterinary physical exam template

Copy this list into your practice management system or a document, and record each item as normal or abnormal with a note on anything abnormal. Write normal findings down as well, so the next vet can see that each system was examined.

Patient and visit

Date and time
Examining vet or nurse
Patient name
Species and breed
Age and sex
Neutering status
Reason for the examination

Vital signs

Weight (kg)
Body condition score, with the scale used
Temperature (°C)
Heart rate (beats per minute) and pulse quality
Respiratory rate (breaths per minute) and effort
Mucous membrane colour
Capillary refill time (seconds)
Hydration status

Body systems (normal or abnormal, with notes)

General demeanour and mentation
Eyes
Ears
Mouth and teeth
Peripheral lymph nodes
Skin and coat
Heart on auscultation
Lungs on auscultation
Abdomen on palpation
Musculoskeletal system and gait
Neurological
Urogenital

Summary

Abnormal findings
Problem list
Plan and further tests

Veterinary medical record template

This template covers the whole record. The first sections are filled in once at registration and updated when something changes, and the consultation entry is repeated for every visit.

Patient details

Name
Species and breed
Sex and neutering status
Date of birth
Colour and markings
Microchip number
Insurer and policy number

Owner details

Name and address
Billing address, if different
Phone number and email
Preferred way to be contacted
Other people allowed to make decisions about the animal

Background

Vaccination history
Current medication
Diet
Known allergies or adverse reactions
Previous conditions and procedures

Consultation entry (one for every visit)

Date and time
Clinician
Reason for the visit
History from the owner
Examination findings, using the physical exam template above
Diagnostics and results
Diagnosis or differentials
Treatment given in the practice
Medicines supplied, with dose and quantity
Consent given and estimate discussed
Advice given to the owner
Plan and recheck date

Where a document template stops

A free template on paper or in a document gives every entry the same shape, which helps keep records consistent between vets. It cannot keep a history of who changed an entry and when, and it cannot link what was done in the consulting room to what the client is charged. Both of those come from keeping the template inside a practice management system. If you are weighing up systems, see our page on the AI veterinary management system.

Where Vetz fits

Vetz listens during the consultation with the owner and writes a structured draft of the clinical note. It works from your practice's own record templates, so the draft follows the layout your team already uses, whether that is SOAP or a template like the one above. Before you sign, Vetz points out parts of the record that are missing, such as the history or the diagnosis, and suggests diagnosis codes and items to bill based on what the note contains.

You read and approve every note before it goes anywhere, and you can edit it by hand or ask Vetz to rephrase or clarify it. Once approved, the note can be transferred straight into your practice management system when the integration is active. Vetz integrates with Provet Cloud and Vettigo. It also works with MHK FileMaker, and bookings from these systems appear in Vetz automatically. The details of the connection are in our article on how Vetz integrates with your practice management system.

Vetz recommends telling owners that AI supports the note-taking, and can provide wording for that. More on how this works in the consulting room is on our page about AI note taking for vets, and the full feature list covers discharge advice for owners and support for more than ten languages.

More about Vetz

If you would like to see Vetz draft a clinical record in your own practice's template, book a demo and we will show you with a layout you already use. You can also try Vetz free for 14 days, and no card details are needed.