Custom Note Template Library

Glossary

General Workup
Procedure
Detailed Discharge
Euthanasia
Spay Surgery
Controlled Substances
Chiropractic
Rehab Exam Discharge Instructions
Integrative Medicine
Blood Work Call Back
Sick Pet
Wellness
Hospitalized Patient
Record with Discharge
Ultrasound
Radiograph
Dental Chart

Canine Templates

Adult Canine Wellness
Dog Spay Surgery
Canine Dental Numbered Chart
Dog Neuter Surgery Report
Dog Neuter Surgery
Puppy 8 weeks History Appointment
Canine Vaccine Plan
Puppy Booster

Feline Templates

Cat Report
Adult Feline Wellness
Kitten Booster

Equine Templates

Equine Dentistry
Equine SOAP

Avian Templates

Exotic Template 1
Exotic Template 2

Other Animals

Farm Animal SOAP
Reptile SOAP
Small Mammal SOAP

How to use

Here is a curated collection of Custom Note Templates that we and our users have created for you to use as is, or to modify as needed. You can also use them for ideas or inspiration on how to lay out your own note.

We have purposefully left off the optional Additional formatting options, as these vary so much between users. For more information on formatting, you can click here.

To use one of these notes:

Open https://app.talkatoo.com/settings/custom-notes
Click + Create a Custom Note
Enter a title.
Copy the given text, then paste it into the main box labeled 1. Initial Command
{Optional} Add any formatting options in the final box labeled 2. Add optional content formatting instructions
Click Save Changes

As many of these templates are from our users, be sure to read them carefully to ensure there are no mistakes or changes you need to make.

And as always, the results of these notes are generated using AI, so it is important to read the results carefully to ensure they are accurate, complete and correct.

General Templates

General Workup

Initial Command

Patient Name:
Veterinarian:
Technician:

**HISTORY**
What problem(s) is your pet experiencing:
When did the problem start:
Is the problem the same, better, or worse:
Has a similar problem happened in the past:
Are any medications being administered:
What is the pet's current diet and feeding schedule:
Eating Changes:
Has your pet been vaccinated recently:
Any weight loss:

Any increase or decrease in water consumption:
Any change in bowel movements:
Any exposure to toxins:
Any other medical history:
Additional Notes:

**EXAM**

Nose and Throat: Normal / Abnormal (Remarks)
Mouth/Teeth/Gum: Normal / Abnormal (Remarks)
Eyes and Ears: Normal / Abnormal (Remarks)
Coat and Skin: Normal / Abnormal (Remarks)
Lymph Nodes: Normal / Abnormal (Remarks)
Legs/Paws/Back: Normal / Abnormal (Remarks)
Nervous System: Normal / Abnormal (Remarks)
Heart and Lungs: Normal / Abnormal (Remarks)
GI Tract/Abdomen: Normal / Abnormal (Remarks)
Urinary and Genitals: Normal / Abnormal (Remarks)

**LABRATORY FINDINGS**
Radiograph: Thorax / Skull / Abdomen / Other view (Remarks)

Bloodwork: (Results)
Urinalysis: (Results)
Fecal: (Results)
Heartworm Test/Triple Snap Test: (Results)
No diagnostics performed

**ASSESSMENT & PLAN**
Assessment & Diagnosis: (To be filled in)
Additional Notes:
Treatment:
Prescriptions:
Plan:

**RECHECK**:

Procedure

Patient Name:

Owner Name:

Species:

Breed:

Age:

Sex:

Weight:

Date of Surgery:

Surgeon:

Assistant:

Anesthetist:

Surgery Start Time:

Surgery End Time:

Pre-Surgical Diagnosis:

Surgical Procedure Performed:

Anesthetic Protocol:

Induction Agent and Dose:

Maintenance Agent and Dose:

Analgesia and Dose:

Surgical Findings:

Surgical Procedure Description (Step-by-Step):

Complications:

Estimated Blood Loss:

Samples Taken (If Any):

Post-Operative Instructions:

Medications Prescribed:

Special Instructions for Owner:

Follow-Up Appointment:

Notes:

Surgeon's Signature:

Date:

Detailed Discharge

**Reason for the Visit:**

**Objective Findings**:

**Treatment Plan**:

**Discharge Summary**:

General Comment on the Visit:

Preventative Care:

Upcoming Appointments:

Diagnosis and Treatment:

Monitoring and Follow-up Instructions:

Closing Remark:

Euthanasia

Humane euthanasia was elected/ General cremation was elected/ Private cremation was elected/ Home buried was elected/ A clay paw print was elected

(patient's name) was sedated with Butorphanol 10 mg/mL ( mL) IM, Dexmedetomidine 0.5 mg/mL ( mL) IM, Ketamine 100 mg/mL ( mL) IM

A gauge IVC was placed in the Right/Left vein

(patient's name) was administered Propofol 10mg/mL ( mL) IV followed by Euthasol 390mg/mL ( mL) IV

(patient's name) was auscultated and confirmed deceased by Dr.

Spay Surgery

Patient presented for . Owner has no questions or concerns at this time.

Scanned patient for a microchip. #

Tech:

BAR. **Temp:**. **Pulse:** **Resp:** WNL. **Gums:** pink/moist. **CRT:** <2.

Placed a. IV catheter in left front leg.

Administered mL Cefazolin mg/mL via sub q injection.

Administered mL Rimadyl mg/mL via sub q injection.

Administered mL of Norm R IV fluids via IV catheter injection.

Collected blood for in-house CBC, Chem 17 and Lytes…see lab for further details…all WNL excepting .

Sedation:

Drugs used for intubation and surgical prep: mL Xylazine mg/mL, mL Atropine mg/mL,

mL Torb mg/mL, mL Ketamine mg/mL and mL Valium mg/mL (only gave mL of Ket/Val combo) via IV catheter injection. Intubated patient with a size. tube and placed patient on ISO/O2 for duration of procedure. Patient received mL of Norm R IV fluids.

Performed routine spay, no complications.

Administered mL of the Ket/Val combo that was previously drawn up Post Op.

Dispensed Cephalexin mg capsules, give capsule orally every 12 hours for 7 days or longer pending patient’s response.

Dispensed Carprofen mg tablets, give tablet orally every 12 hours for 2-4 days STARTING tomorrow morning, if patient is doing well reduce to 1/2 tablet orally every 24 hours for 3-4 more days.

See discharge instructions attached to record for further details.

Controlled Substances

Date:

Client Name:

ID#:

Pet Name:

Species:

Ordered by:

Dispensed/Administered by:

Amount Dispensed or Administered:

Chiropractic

**Prior Manipulation?:**

**History:**

**Posture/Ambling Notes:**

**Static Palpation:**

**Motion Palpation:**

**C0:**
**C1:**
**C2:**
**C3:**
**C4:**
**C5:**
**C6:**
**C7:**

**T1:**
**T2:**
**T3:**
**T4:**
**T5:**
**T6:**
**T7:**
**T8:**
**T9:**
**T10:**
**T11:**
**T12:**
**T13:**

**L1:**
**L2:**
**L3:**
**L4:**
**L5:**
**L6:**
**L7:**

**Sternum:**
**Rib:**

**Pelvis:**
**SACRUM:**

**Forelimbs:**
**Digit:**
**MC:**
**Acc, Carp:**
**Olec: Right:**
**Olec: Left:**
**Hum: Right:**
**Hum: Left:**
**Scap: Right:**

**Hindlimbs:**
**Digit:**
**MT:**
**Calc: Right:**
**Calc: Left:**
**Tibia: Right:**
**Tibia: Left:**
**Femur: Right:**
**Femur: Left:**

**Recommendations:**

Rehab Exam Discharge Instructions

**Presenting Complaint:**

**Physical and Diagnostic Examination:**

**GaitRite Objective Gait Analysis:**

**Diagnostic MSK Ultrasound: Final report pending
Medications:**
Please continue all medications and supplements as previously directed.

**Glucosamine and Chondroitin Sulfate: Dasuquin Advanced (Nutramax Labs) is recommended.
Joint health is an important aspect of your pet's recovery as well as long-term function.
Dasuquin Advanced is a joint health supplement that works by supporting cartilage production and blocking enzymes that break down cartilage within the joint. We specifically recommend this product as it is the only veterinary joint supplement with clinical studies to support its
eficacy. In addition to glucosamine and chondroitin sulfate, Dasuquin Advanced also contains avocado and soy as well as antioxidants which would benefit overall health.
Omega-3 fatty acid supplements (EPA and DHA) in liquid form, from marine sources are recommended. Welactin (from Nutramax Labs) is recommended. While using this supplement it is important to monitor for weight gain or digestive upset. If these concerns arise, diet planning
or dose reduction may be needed.
*If purchasing Welactin, the liquid formulation of Welactin is preferred. Please double the listed body weight dose given on the label (a slow gradual progression to this amount is recommended over 2 weeks while monitoring for gastric upset).
Myos Canine Muscle Formula: Research has shown that better muscle heath leads to better mobility, vitality and quality of life. Myos Canine Muscle Formula is made from an all-natural ingredient Fortetropin (fertilized hen egg yolks). It is considered a natural myostatin-reducing agent and has been clinically proven to increase muscle mass and size. Additionally, itIs been shown to inhibit disuse muscle atrophy in dogs after surgery.
Adequan (polysulfated glycosaminoglycan) is an FDA-approved disease-modifying osteoarthritis drug. It is administered via subcutaneous (under the skin) or intramuscular injections to control signs associated with joint arthritis. Please speak with your primary veterinarian regarding this medication. We recommend dosing at 2 mg/lb, starting with twice
weekly injections for 4 weeks. Following that, you may continue once monthly injections as long as the medication appears to be helping, or you can repeat this series during times of increased discomfort. These continued injections can be performed by your primary veterinarian, or you
can administer the injection at home following instruction by your veterinarian if you are comfortable.

Comments:

Physical Therapy

Fill out this blank medical record based on the transcript below:

**Patient's Name:**
**Date:**

**PHYSICAL EXAMINATION:**
**Skin/Incisions:**
**Heart rate:**
**Color/temp:**
**Respirations:**
**Musculoskeletal:**
**Skin:**
**Cardiovascular:**
**Neurological:**

**POSTURE/GAIT:**
**General Observation:**
**Preop/Injury Lameness:** Walk: Trot:
**Postop/Injury Lameness:** Walk: Trot:
**Standing Limb Position:**
**Sitting Limb Position:**
**Circumference(cm):**
- 70% Femur: Affected/Unaffected Other:
- 80% Humerus: Affected/Unaffected Other:
- Joint Line: Affected/Unaffected Other:
- Other:

**RANGE OF MOTION:**
**Hip:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
*Stifle:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
**Hock:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
**Shoulder:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
**Elbow:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
**Carpus:** Flexion: Extension: AB/Adduction: Varus/Valgus: Other:
**Other:**

**PALPATION:**
**Forelimb:**
**Hind Limb:**
**Spine:**
**Other:**

**SPECIAL TESTS:**
**Neurologic:**
**Orthopedic:**
**Functional:**
**Other:**

**TREATMENT:**

**Modalities:** Interferential Current OR Neuromuscular Electrical Stimulation OR Other Stim OR Ultrasound OR Ice OR Heat OR Other
**Manual:** Massage OR Joint Mobilization OR Passive Range of Motion OR Other:
**TherEx:** Gait Training OR Aquatic OR Functional OR Swiss Ball OR Foam Roll OR Owner Education OR Protocol Review OR Other:

**ASSESSMENT/GOALS:**
**Decrease Pain:**
**Decrease Edema:**
**Increase Weight-bearing:**
**Independent Home Exercise Program:**
**Return to Previous Function:**
**Other:**

**PLAN:**
**Return Visit:**
**Call for Follow-up:**
**Call DVM:**
**Other:**

DVM Signature:

Integrative Medicine

**SUBJECTIVE:**

**History**:
**Chief Complaint**:
**Clinical Findings:**

**Previous history:**

**Current Medications:**

Acupuncture visit # :
Patient Physical Examination :
Temperature:
Weight:
Pulse:
RR:
MM:
CRT:
Tongue:
Constitution:
Diet:
Body Score:
Shen:
Voice:
Activity Level:
Sleep:
Temp Pref:
Appetite:
Thirst:
Urination:
Coughing:
Sneezing:
Panting:
Vomiting:
Stool:
Stiffness:
Weakness:
Hearing Loss:
Likes Massage:
Paw pads:
Pain:

**OBJECTIVE:**
Body Condition: Your pet's body condition and weight are normal. There is a slightly tucked-in waist and the ribs and spine are palpable.
Ears: Both the ear canal and pinna are normal. Your pet's tympanic membrane (ear drum) is normal and your pet seems to hear fine.
Eyes: Your pet's eye(s) are normal. The eyeball, eyelids and associated structures appear normal. Your pet appears to have normal vision.
GI/Abdominal Palpation: Your pet's abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).
Heart/Cardiovascular: Your pet's heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.
Lungs/Trachea: Your pet's lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.
Lymph nodes/Thyroid gland: Your pet's external lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland.
Mouth/Teeth/Gums: Your pet's oral examination is normal. There is no evidence of tartar on the teeth or gum disease.
Musculoskeletal: Your pet's muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
Nervous System: Your pet's nervous system is normal. There are no observable defects in the nerves, spine cord or brain function.
Nose/Throat: Your pet's nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.
Skin/Haircoat: Your pet's haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.
Urinary/Reproductive: Your pet's urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.

**ASSESSMENT:**

**Differential Diagnosis**:
**Pattern Diagnosis:**

**PLAN :**

**Acupuncture:**
**Local Point:**
**Topographic:**
**Electro-accupuncture:**
**Moxabustion:**
**Acupuncture Points Used:**

**Laser:**
**Chiropractic Listings:**
Takehome Instructions:

Discussed with owner: Alternative/Complimentary/Integrative Veterinary care is not intended to replace the services of conventional medicine. We offer information along with our suggested treatment plans, It should not be misconstrued to mean, imply, or indicate that the products or treatment plans described cure anything, as no such claims are made. ONLY THE BODY CAN HEAL ITSELF, so the nutritional and herbal supplements are not offered as a cure, but rather as aids to the body in re-establishing normal functions.

If clinical signs persist in spite of treatment further diagnostics/treatments may be warranted.

Blood Work Call Back

Write a formal and detailed diagnostic report including current abnormal values, previous abnormal values, normal reference range, diagnostic interpretation, and relevant information to any values out of the reference range using the blood work summary and information provided. Separate values by *Chemistry*, *Complete Blood Cell Count*, *Heartworm/Tick Borne Illness Test*, *Thyroid Testing*, *Urinalysis*, *Fecal Results*, and *Additional Testing*.

Blood work summary:

**Kidney values:**

- BUN (blood urea nitrogen): Increases with decreased kidney function, dehydration, heart disease, gastrointestinal bleeding, shock, urinary obstruction, high protein diet; decreases with overhydration.

- CREA (creatinine): Increases with decreased kidney function, other conditions noted with BUN (excluding recent high protein diet); decreases with overhydration or reduced muscle mass.

- PHOS (phosphorus): Increases with kidney disease, increased intake through the gastrointestinal tract, tissue injury; decreases with increased loss or decreased intake.

- Ca+ (calcium): Increases with kidney disease, certain cancers, toxicities, parathyroid disease; decreases with certain parathyroid diseases and low albumin.

**Liver values:**

- ALT (alanine aminotransferase): Increases indicate liver cell damage.

- ALKP (alkaline phosphatase): Increases indicate liver abnormality, Cushings disease, bone growth in young pets, bone remodeling after injury, drug-induced conditions.

- GGT (gamma-glutamyl transferase): Increases indicate liver abnormality or hemolysis.

- ALB (albumin): Increases may indicate dehydration or stress; decreases with decreased liver function, blood loss, gastrointestinal or kidney disease.

- TBIL (total bilirubin): Increases with liver disease or anemia, leading to jaundice.

- Bile acids: Increases indicate decreased liver function, abnormalities in blood flow to the liver, or bile duct obstruction.

**Pancreatic values:**

- AMYL (amylase): Increases with pancreatitis, kidney disease, gastrointestinal disease.

- LIPA (lipase): Increases with pancreatitis, kidney disease, gastrointestinal disease.

**Protein profile:**

- TP (total protein): Increases may indicate dehydration, stress, inflammation; decreases with decreased liver function, blood loss, gastrointestinal or kidney loss.

- ALB (albumin): Increases may indicate dehydration or stress; decreases with liver function decline, blood loss, gastrointestinal or kidney disease.

- GLOB (globulin): Increases may indicate inflammation or infection; decreases with blood loss, gastrointestinal loss, immune deficiencies.

**Electrolytes:**

- Na+ (sodium): Increases may indicate dehydration; decreases with loss during diarrhea, vomiting, Addisons disease, kidney disease.

- K+ (potassium): Increases with kidney disease, Addisons disease, dehydration, kidney obstruction; decreases with diarrhea or vomiting.

- Cl- (chloride): Increases may indicate dehydration; decreases with diarrhea or vomiting.

**Miscellaneous chemistries:**

- GLU (glucose): Increases may indicate diabetes mellitus; decreases due to liver disease, pancreatic disease, seizure, coma.

- AST (aspartate aminotransferase): Increases associated with liver or muscle damage.

- CK (creatine kinase): Increases associated with muscle damage.

- CHOL (cholesterol): Increases with metabolic disturbances including diabetes mellitus, hypothyroidism, Cushings disease, pancreatitis, some kidney diseases; decreases with liver insufficiency, intestinal disease.

- TRIG (triglycerides): Increases in non-fasted samples, schnauzers, pancreatitis, diabetes, Cushings disease, hypothyroidism.

- Cortisol: Increases with Cushings disease; decreases with Addisons disease.

- T4 (thyroxine): Increases indicate hyperthyroidism; decreases indicate hypothyroidism.

- LACTATE: Increases indicate decreased blood perfusion, can be a prognostic indicator for critical patients.

**Red Blood Cell Parameters (RBC):**

- RBC, HCT, HGB (red blood cell count, hematocrit, hemoglobin): Increases indicate dehydration, stress, or increased production of RBCs; decreases indicate anemia and decreased oxygen-carrying capability of the blood.

- MCV (mean cell volume): Increases indicate larger than normal cells, often due to young cells during anemia response; decreases indicate smaller than normal cells, associated with chronic blood loss or iron deficiency.

- MCH (mean cell hemoglobin) and MCHC (mean cell hemoglobin concentration): Increases suggest hemolysis; decreases suggest decreased hemoglobin concentration, anemia, or chronic blood loss.

- RDW (red cell distribution width): Increases indicate variability in cell size.

- RETIC (reticulocytes): Increases indicate a growing number of immature RBCs, suggesting a response to RBC demand; decreases indicate few or no immature RBCs, suggesting the body cannot respond to RBC demand (nonregenerative anemia).

**White Blood Cell Parameters:**

- WBC (white blood cells): Increases may be due to inflammation, stress, excitement, steroid use, leukemia; decreases may be due to overwhelming inflammation/infection, and bone marrow failure.

- Leukocyte Differential:

  - NEU (neutrophils): Acute responders within 1 to 3 days to infectious and inflammatory disease processes. Elevations can also be seen with stress or Cushings.

  - LYM (lymphocytes): Increases with stress, chronic infection; decreases can be caused by stress.

  - MONO (monocytes): Changes indicate chronic infection or inflammation, often indicating issues over 3 to 5 days. Elevations can also be seen with stress or Cushings.

  - EOS (eosinophils): Increase with parasitic disease, hypersensitivity, and allergy; decreases can be seen with stress.

  - BASO (basophils): Increase with parasitic disease, hypersensitivity, and allergy.

**Platelet Parameters:**

- PLT (platelet) and PCT (platelet crit): Increases in the overall platelet mass may indicate a hypercoagulable state; decreases may be due to decreased production (bone marrow failure), increased consumption (coagulation, inflammation), and destruction in the blood (infectious, immune-mediated)or clumping of sample which can be confirmed with blood film evaluation..

- MPV (mean platelet volume): Increases indicate larger than normal platelets.

- PDW (platelet distribution width): Increases in variability of platelet size indicate a response to platelet demand; decreases may indicate immune-mediated thrombocytopenia.

**Urinalysis:**

- Specific Gravity: Indicates kidney function and hydration.

- pH: Reflects acid-base status.

- PRO (protein): Larger amounts may indicate kidney disease.

- GLU (glucose): High levels usually indicate elevated blood glucose concentration.

- KET (ketones): Elevated levels indicate lipid breakdown or advanced, unregulated diabetes.

- UBG (urobilinogen): High levels may indicate liver or hemolytic disease.

- BIL (bilirubin): High levels may indicate liver or hemolytic disease; significant in cats, normal in dogs especially males.

- RBCs and Hemoglobin: Indicate inflammation, infection, or trauma.

- WBCs: Indicate urinary tract inflammation.

- UPC (urine protein/creatinine ratio): Indicates significant protein loss through the kidney.

**Other tests:**

- Canine/Feline Giardia: Tests for a protozoan parasite.

- Canine/Feline Heartworm: Tests for heart and lung parasites.

- Canine Tick-Borne diseases: Tests for Lyme disease, ehrlichiosis, anaplasmosis.

- Canine Parvovirus: Tests for viral, deadly gastrointestinal disease in dogs and cats.

- FIV/FeLV (Feline Immunodeficiency Virus/Feline Leukemia Viruses): Tests for major causes of infectious viral illness in cats.

Sick Pet

Use the information provided to write a formal medical record. Include physical exam findings, diagnostic results and interpretation, complete problem list with differentials, treatments and medications, declined recommendations, discussion and recommendations, monitoring information, and rechecks. Write a formal diagnostic report using the information provided. Make a complete problem list with the information provided. Write detailed medication instructions for the owner with information provided. Make the discussion and recommendations detailed.
**Physical Exam:**
**Diagnostic results:**
**Interpretation:**
**Problem list:**
**Treatments and medications:**
**Recommendations**
**Declined recommendations:**
**Discussion and information:**
**Medication Instructions for Owner:**
**At home care instructions:**
**Rechecks:**
**Discharge Information:**
**Additional information:**
Sign
**This record is written using a dictation service. Please excuse any spelling and grammatical errors.**

Include more information and details. Edit the following physical exam template using the information provided.
Physical Exam:
Temperature: Not performed.
Heart Rate: No count performed, but subjectively normal.
Respiratory rate/effort: Normal effort/rate
Mucus Membranes: Pink, moist mucous membranes
Capillary Refill Time: CRT <2s
Hydration: Euhydrated
Weight:
Body Condition Score: Body condition and weight are normal. There is a slightly tucked-in waist and the ribs and spine are palpable.
Behavior/Mentation: Bright, alert, responsive, appropriate mentation.
Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.
Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.
Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).
Gastrointestinal System: Gastrointestinal system is normal.
Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.
Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.
Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).
Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.
Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.
Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.
Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.
Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.
Rectal: Not performed. No outwardly perineal abnormalities noted.

Wellness

Use the information provided to write a formal and very detailed medical record. Include physical exam findings, diagnostic results and interpretation, complete problem list with differentials, treatments and vaccines, prevention and medications dispensed, declined recommendations, discussion and recommendations, and rechecks. State where the vaccines were given. Provide specific information regarding weight management, and diet recommendations. Include recommendation for owner to monitor for vaccine reactions including facial swelling hives vomiting and diarrhea. Include this signature at the bottom of the record:
Thank you for trusting us with your pet’s care!
Best regards,

**Note:** The record is written using a dictation service and to please excuse any spelling and grammatical errors at the bottom of the record.

Include more details and information. Edit the following physical exam template using the information provided.

Physical Exam: Temperature: Not performed.
Heart Rate: No count taken, but subjectively normal.
Respiratory rate/effort: Normal.
Mucus Membranes: Pink, moist mucous membranes
Capillary Refill Time: CRT \<2s
Hydration: Euhydrated
Pain Score: 0/5
Weight:
Body Condition Score: Body condition and weight are normal. There is a slightly tucked-in waist and the ribs and spine are palpable.
Behavior/Mentation: Bright, alert, responsive, appropriate mentation.
Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.
Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.
Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).
Gastrointestinal System: Gastrointestinal system is normal.
Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.
Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.
Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).
Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.
Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.
Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.
Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.
Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.
Rectal: Not performed. No outwardly perineal abnormalities noted.

Hospitalized Patient

Write a formal and detailed medical record with the following categories filled in based on the transcript below the template:
**Presenting Complaint & Diagnosis:**
**Rounds summary:**
**Subjective:**
**Physical Exam:**
**Diagnostic Results:**
**Diagnostic Interpretation:**
** Pending Diagnostics:**
**Problem List:**
**Treatment Plan:**
**Recommendations:**
**Estimate and current charges**
**Client Communication/Discussion:**
**Discharge Instructions:**

Put two asterisks on the left and right side of each section header.
Use the following body systems and defaults for the physical exam section:
Temperature:
Heart Rate:
Respiratory rate/effort:
Mucus Membranes:
Capillary Refill Time:
Hydration:
Weight:
Body Condition Score:
Behavior/Mentation:
Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.
Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.
Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).
Gastrointestinal System: Gastrointestinal system is normal.
Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.
Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.
Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).
Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.
Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.
Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.
Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.
Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.
Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.
Rectal: Not performed. No outwardly perineal abnormalities noted.
Diagnostic results section must include detailed and well-organized laboratory report and formal imaging report. Separate values by *Chemistry*, *Complete Blood Cell Count*, *Heartworm/Tick Borne Illness Test*, *Pancreatic Lipase*, *Thyroid Testing*, *Urinalysis*, *Fecal Results*, *POCUS/FAST Scan*, *Radiograph Report*, and *Additional Testing*.

Record with Discharge

Use the information provided to write a formal and very detailed medical record for patient. Edit the following template using the information provided.

**Chief Complaint**

[Enter Chief Complaint]

**History**

[Enter History]

**Current Medications**

[Enter Current Medications]

**Medical History**

[Enter Medical History]

**Recent Diagnostics (rDVM)**

[Enter Recent Diagnostics]

**Known Allergies**

[Enter Known Allergies]

**Diet**

[Enter Diet]

**Vaccine Status**

[Enter Vaccine Status]

**Vitals**

Weight: [Enter Weight]

Temperature: [Enter Temperature]

Pulse/Heart Rate: [Enter Pulse/Heart Rate]

Respiratory Rate: [Enter Respiratory Rate]

Respiratory Effort: [Enter Respiratory Effort]

Mucous Membranes: [Enter Mucous Membranes]

Capillary Refill Time (CRT): [Enter CRT]

**Physical Exam**

[Enter Physical Exam]

**Diagnostics Performed**

[Enter Diagnostics Performed]

**Pending Diagnostics**

[Enter Pending Diagnostics]

**Therapeutic Plans & Procedures**

[Enter Therapeutic Plans & Procedures]

**Tentative Diagnosis**

**Problem List/Tentative Diagnosis**

[Enter Problem List/Tentative Diagnosis]

**Hospitalization Summary**

[Enter Hospitalization Summary]

**Diagnosis**

[Enter Diagnosis]

**Discharge**

**Diet**

[Enter Discharge Diet]

**Medications**

[Enter Discharge Medications]

**Recommended Recheck**

[Enter Recommended Recheck]

**Additional Instructions**

[Enter Additional Instructions]

Include more information and details. Edit the following physical exam template using the information provided.

Temperature: Not performed.

Heart Rate: No count performed, but subjectively normal.

Respiratory rate/effort: Normal effort/rate

Mucus Membranes: Pink, moist mucous membranes

Capillary Refill Time: CRT <2s

Hydration: Euhydrated

Weight:

Body Condition Score: Body condition and weight are normal. There is a slightly tucked-in waist and the ribs and spine are palpable.

Behavior/Mentation: Bright, alert, responsive, appropriate mentation.

Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.

Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.

Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).

Gastrointestinal System: Gastrointestinal system is normal.

Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.

Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.

Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).

Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.

Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.

Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.

Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.

Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.

Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.

Rectal: Not performed. No outwardly perineal abnormalities noted.

Include this signature at the bottom of the record:

Warm regards,

**This record is written using a dictation service. Please excuse any spelling and grammatical errors.**

Ultrasound

Use the information provided to write a formal and detailed ultrasound report. Make it well organized. Include findings, a problem list and differentials, interpretation, recommendations, and rechecks.

Radiographs

Use the information provided to write a formal and detailed radiology report. Make it well organized. Include findings, a problem list and differentials, interpretation, recommendations, and rechecks.

Dental Chart

**Client Information:**

- Client Name:

- Address:

- Phone Number:

- Email:

**Pet Information:**

- Pet Name:

- Species:

- Breed:

- Age:

- Weight:

- Gender:

- Microchip Number:

**Appointment Details:**

- Date of Exam:

- Time of Exam:

- Veterinarian’s Name:

**Subjective:**

- Reason for Visit:

- Dental History:

- Current Medications:

- Known Allergies:

**Objective:**

- Physical Exam Findings:

- Dental Charting (Numbered Names of Each Tooth):

**Upper Right Quadrant (101-110):**

    - 101: Incisor

    - 102: Incisor

    - 103: Incisor

    - 104: Canine

    - 105: Premolar

    - 106: Premolar

    - 107: Premolar

    - 108: Premolar

    - 109: Molar

    - 110: Molar

  **Upper Left Quadrant (201-210):**

    - 201: Incisor

    - 202: Incisor

    - 203: Incisor

    - 204: Canine

    - 205: Premolar

    - 206: Premolar

    - 207: Premolar

    - 208: Premolar

    - 209: Molar

    - 210: Molar

**Lower Left Quadrant (301-311):**

    - 301: Incisor

    - 302: Incisor

    - 303: Incisor

    - 304: Canine

    - 305: Premolar

    - 306: Premolar

    - 307: Premolar

    - 308: Premolar

    - 309: Molar

    - 310: Molar

    - 311: Molar

  **Lower Right Quadrant (401-411):**

    - 401: Incisor

    - 402: Incisor

    - 403: Incisor

    - 404: Canine

    - 405: Premolar

    - 406: Premolar

    - 407: Premolar

    - 408: Premolar

    - 409: Molar

    - 410: Molar

    - 411: Molar

**Diagnostic Tests:**

  - Radiographs:

  - Blood Work:

  - Other Tests:

**Assessment:**

- Diagnosis:

- Summary of Findings:

**Plan:**

- Treatment Performed:

  - Dental Cleaning:

  - Tooth Extractions:

  - Periodontal Treatment:

  - Other Procedures:

- Post-Procedure Care Instructions:

  - Medications:

  - Follow-up Appointments:

  - Home Dental Care Recommendations:

- Client Education:

  - Discussed Prevention:

  - Provided Dental Care Brochures:

**Follow-Up:**

- Next Appointment:

- Additional Notes:

**Signatures:**

- Veterinarian Signature:

- Date:

- Client Signature:

- Date:

Canine Templates

Adult Canine Wellness

**Consultation history:**
Date:

**POST APPOINTMENT INSTRUCTIONS:**

**Meds:**
**Recheck:**
**Other notes (dc notes, bill, food, etc):**
**RTG?:**

**History:** Routine examination for vaccinations. Doing well at home. Eating and drinking normally. No owner or patient concerns. Good E level/appetite. No v/d/c/s. Normal urine/thirst/feces. **Staff initials:**

**Anal gland expression?**
**Nail trim?**
**Current meds/deworming:**
**Current diet (grain-inclusive? legume-free?):**

**Temperature:** C (aural)
**Pulse:** bpm
**Respiration:** brpm
**Body Condition Score:** BCS 5/9
**Attitude:** BAR, friendly
**Oral cavity/MMs:** MMs pink, moist, CRT<2 sec
**Cardiovascular:** No murmur or arrhythmia auscultated
**Teeth:** NSF
**Respiration:** Clear in all fields, no crackles or wheezes
**Lymph nodes:** Peripheral lymph nodes normal size and symmetrical
**Eyes:** Clear
**Ears:** Clean
**Nasal:** NSF
**Abdominal Palpation:** Soft and comfortable throughout
**Musculoskeletal:** NSF
**Genitourinary:** NSF
**Integumentary:** NSF
**Rectal:** Not examined today
**Nervous:** NSF

**Diagnostics:**

**SNAP4dx -**
**CBC:** n/a
**CHEM/LYTES:** n/a
**Radiographs:** n/a
**Cytology:** n/a

**Vaccinations:**

DH2PP L scap SQ (Vanguard5serial #, expiration:) - **repeat in 1 year/3 years**
Rabies R scap SQ (Defensor3 serial #, expiration:) - **repeat in 1 year/ 3 years**
Bord oral (Nobivac serial #, expiration:) - **repeat in 1 year**
Bord injectable (Vanguard serial #, expiration:) - **repeat in 1 month/year**
Lyme LH SQ (Vanguard, serial #, expiration:) - **repeat in 1 month/1 year**

**Treatment Plan/ Recommendations/ Medications to go home:**

Discussed PE findings and potential vx reactions; no vx 100% protective
Recommend deworming
Recommend flea/tick prevention, Recommend heartworm prevention
Recommend grain inclusive, low legume based diet

Dog Spay Surgery

Pre-Surgical Exam

Pre-Surgical blood work = [add abnormal], otherwise, WNL

**Premeds:**

-Butorphanol 10 mg/mL ( mL) IV

-Buprenorphine 0.5 mg/mL ( mL) IV

-Buprenorphine 0.3 mg/mL ( mL) IV

-Hydromorphone 2 mg/mL ( mL) IV

-Midazolam 5mg/mL ( mL) IV

-Acepromazine 10 mg/mL ( mL) IV

-Acepromazine 1 mg/mL ( mL) IV

-Dexmedetomidine 0.5 mg/mL ( mL) IV

-Ketamine 100mg/mL ( mL) IV

-Alfaxalone 10mg ( mL) IV

**Antiemetics:**

-Cerenia 10 mg/mL ( mL) IV

-Ondansetron 2mg/mL ( mL IV

-Vitamin B12 ( mL) SQ

Placed IVC = gauge R / L cephalic vein

**Routine induction:**

-Propofol 10mg/mL ( mL) IV to effect

-Alfaxalone 10mg/mL ( mL) IV to effect

**Intra-op meds:**

-Lidocaine 20 mg/mL ( mL) local line block

-Bupivacaine 5 mg/mL ( mL) local line block

**Post-op meds:**

-Carprofen 50 mg/mL ( mL) SQ,

-Meloxicam 5mg/mL ( mL) SQ

-Buprenorphine 0.5 mg/mL ( mL) IV

-Buprenorphine 0.3 mg/mL ( mL) IV

-Antisedan 5mg/mL ( mL) IM

-Vitamin B12 ( mL) SQ

Total LRS IVF volume mL

Routine Spay/OVH

-See attachment for anesthesia monitoring

-Notes: uneventful anesthesia

Uneventful recovery

Pulled IVC prior to discharge

E-collar = cm

Microchip

RX:

-Carprofen mg tablets: tab PO q12h x 5d qty: / refills 0

-Gabapentin mg capsules/tablets: tab/cap PO q8-12h x 5 qty: / refills: 1

-Trazodone mg tablets: tab PO q8-12h x 7d qty: . refills 1

-Gabapentin mg/mL suspension: mL PO q8-12h x 5 qty: / refills 1

-Meloxicam mg/m suspensionL: mL PO q12h x 5d qty: / refills:0

Written RX:

-Trazodone mg/mL suspension: mL PO q8-12h x 7d qty: . refills

Prognosis: Good

Follow-up: 1 year for an annual exam or sooner if surgical concerns/complications

Client Education: Advised Owner to feed 1/2 has much food tonight & resume normal feeding tomorrow. Monitor for signs of GI upset, such as vomiting and diarrhea. Advised owner to keep patient relaxed for the rest of the day to sleep off effects of the anesthesia. Advised removal of bandage in place secondary to IV catheter removal when arriving home. Standard Hippo Spay discharge instructions handout given.

Canine Dental Numbered Chart

**Right Upper Quadrant**
101:
102:
103:
104:
105:
106:
107:
108:
109:
110:

**Left Upper Quadrant**
201:
202:
203:
204:
205:
206:
207:
208:
209:
210:

**Left Lower Quadrant**
301:
302:
303:
304:
305:
306:
307:
308:
309:
310:
311:

**Right Lower Quadrant**
401:
402:
403:
404:
405:
406:
407:
408:
409:
410:
411:

Dog Neuter Surgery Report

The patient was placed in dorsal recumbency and the surgical site was clipped of hair. The prescrotal region was scrubbed with chlorhexidine and alcohol allowing for 5 minutes of contact time. The prescrotal region was draped in a sterile manner. A cm skin incision was made with a #10 blade in the prescrotal region. The subcutaneous tissue was sharply incised to the level of the external spermatic fascia. The left testis was exteriorized and the spermatic fascia stripped via manual traction. The spermatic cord and vessels were double ligated with 2 modified Miller's knots. The testicle was sharply exercised. Hemostasis was ensured before releasing the transected cord. The right testicle was excised in the same manner. The subcutaneous tissue and skin were closed via routine two-layer closure.

Subcutaneous closure as follows: Simple continuous

Skin closure as follows: Buried continuous intradermal with skin glue as needed

Suture material utilized: PDS

Dog Neuter Surgery

Pre-Surgical Exam

Pre-Surgical blood work = (add abnormal), otherwise, WNL

**Premeds:**

-Butorphanol 10 mg/mL ( mL) IV

-Buprenorphine 0.5 mg/mL ( mL) IV

-Buprenorphine 0.3 mg/mL ( mL) IV

-Hydromorphone 2 mg/mL ( mL) IV

-Midazolam 5mg/mL ( mL) IV

-Acepromazine 10 mg/mL ( mL) IV

-Acepromazine 1 mg/mL ( mL) IV

-Dexmedetomidine 0.5 mg/mL ( mL) IV

-Ketamine 100mg/mL ( mL) IV

-Alfaxalone 10mg ( mL) IV

**Antiemetics:**

-Cerenia 10 mg/mL ( mL) IV

-Ondansetron 2mg/mL ( mL IV

Placed IVC = gauge R / L cephalic vein

**Routine induction:**

-Propofol 10mg/mL ( mL) IV to effect

-Alfaxalone 10mg/mL ( mL) IV to effect

**Intra-op meds:**

-Lidocaine 20 mg/mL ( mL) local spermatic cord block

-Bupivacaine 5 mg/mL ( mL) local spermatic cord block

**Post-op meds:**

-Carprofen 50 mg/mL ( mL) SQ,

-Meloxicam 5mg/mL ( mL) SQ

-Buprenorphine 0.5 mg/mL ( mL) IV

-Buprenorphine 0.3 mg/mL ( mL) IV

-Antisedan 5mg/mL ( mL) IM

-Vitamin B12 ( mL) SQ

Total LRS IVF volume mL

Routine Neuter/Castration

-See attachment for anesthesia monitoring

-Notes: uneventful anesthesia

Uneventful recovery

Pulled IVC prior to discharge

E-collar = cm

Microchip:

RX:

-Carprofen mg tablets: tab PO q12h x 5d qty: / refills 0

-Gabapentin mg capsules/tablets: tab/cap PO q8-12h x 5 qty: / refills: 1

-Trazodone mg tablets: tab PO q8-12h x 7d qty: . refills 1

-Gabapentin mg/mL suspension: mL PO q8-12h x 5 qty: / refills 1

-Meloxicam mg/m suspensionL: mL PO q12h x 5d qty: / refills:0

Written RX:

-Trazodone mg/mL suspension: mL PO q8-12h x 7d qty: . refills 1

Prognosis: Good

Follow-up: 1 year for an annual exam or sooner if surgical concerns/complications

Client Education: Advised Owner to feed 1/2 has much food tonight & resume normal feeding tomorrow. Monitor for signs of GI upset, such as vomiting and diarrhea. Advised owner to keep patient relaxed for the rest of the day to sleep off effects of the anesthesia. Advised removal of bandage in place secondary to IV catheter removal when arriving home. Standard Hippo Neuter discharge instructions handout given.

Puppy 8 weeks History Appointment

Date:
Initials:
DVM:
Tech:

Confirmed contact information with owner?

Anyone else need to be added to the file?

Acquired: from a breeder/ from a shelter./from a private party./as a stray.

When?

Health Concerns with {AnimalName}?

Eating habits and diet fed:

Dietary recommendation:

Drinking?

Vomiting?

Diarrhea?

Urination:

Energy level:

Medications (name, doses):

Previous vaccines?

Vaccine reactions?

Discuss vaccination series (Lepto & Lyme):

Review vaccine schedule & importance of yearly health exam:

Vaccine receiving today:

Discuss intestinal parasites & deworming:

Discuss fleas (if applicable):

Discuss HW disease and testing:

Stool sample today and yearly recommended:

Pet insurance trial discussed: Yes/No/Declined/Accepted

Courtesy nail trim? Yes/No

Prebook next visit (book 1 month booster during tech exam)

Issues to address:

**Temperament:**Friendly/Shy/Caution
**Mentation**:BAR/QAR/Dull and Depressed
**mmb colour**:pink/pale pink/pale/purple/blue
**CRT**: <1sec/<2sec/>2sec
**BCS**:
**SARCOPENIA**: NONE-well muscled/mild muscle wasting/moderate muscle wasting/severe muscle wasting

**Hydration Status**: Normal/4-6% hydration/6-8% dehydration/8-10% dehydration

**Integument:**Normal/Abnormal

Eyes:

Ears:

Nose:

Throat:

**Oral Cavity:** Teeth are free from excessive tartar, no gingivitis present/grade 1 periodontal disease/grade 2 periodontal disease/grade 3 periodontal disease/severe periodontal disease occlusion-/normal bite/overbite (type 2 malocclusion) /underbite (type 3 malocclusion)

**Cardiovascular:**Regular rhythm; no murmur detected/heart murmur present

**Respiratory:**Lungs auscultate clear; trachea clear/Abnormal

ABDOMEN/soft non-painful with no palpable masses/tense on palpation/too large for accurate palpation

Genitourinary: {AnimalSexFull}:

Musculoskeletal:

**Neurologic:**No apparent abnormalities/Ambulatory x 4 with no apparent lameness/Abnormal

Lymph Nodes:

**Assessment:**

**Plan:**
Rx: Vaccines (location given):
Medications to go home (dosing calculations with final dosing to go home, duration):
Next steps for the pet:
Next visit:
Any outstanding items needing to be addressed:

Canine Vaccine Plan

**Subjective:**
Presenting for/ DA2PPV/ DA2PPV and Rabies/ DA2PPV and Bordetella inj/ DA2PPV, Bordetella inj and Rabies/ Bordetella/ Bordetella inj and Rabies/ Rabies/ Bordetella oral/ DA2PPV and Bordetella oral/ DA2PPV, Bordetella oral and Rabies]
Eating and drinking: normal
Energy levels: normal
Urinating and defecating: normal
Feces consistency: normal
Food:
Owner concerns:

**Objective:**
Demeanor:
Mentiation: BAR
MM: pink, CRT<2s
Heart: Normal heart and lung sounds, strong synchronous pulses, normal Broncho vesicular sounds
Eyes: appear normal
Ears: appear healthy
Integument: normal
Lymph nodes: palpate normal
Abdomen: palpates normal, no organomegaly appreciated
Mentation: normal
Rectum: appears normal
Dentition: normal
Stifles: normal
Mammary chain: normal
Genital: Both testis descended/ unilateral crypt rt side/ unilateral crypt left side
BCS: /5

**Plan:**
{name} [Vaccinated for/ DA2PPV/ DA2PPV and Rabies/ DA2PPV and Bordetella inj/ DA2PPV, Bordetella inj and Rabies/ Bordetella/ Bordetella inj and Rabies/ Rabies/ Bordetella oral/ DA2PPV and Bordetella oral/ DA2PPV, Bordetella oral and Rabies]
Discussed with owner Echinococcus multilocularis:/ Yes/ No]
Dispensed 1 dose Dolpac/ Dispensed 6 months Dolpac/ Dispensed 12 months Dolpac/ Owner declined deworming/ Dispensed 12 doses Biltricide]
Dispensed Bravecto/ Yellow/ Orange/ Green/ Blue/ Pink]
Discussed with owner omega III supplementation:/ Yes/ No]

Puppy Booster

Write a formal and very detailed medical record for a patient including the relevant history, physical exam, diagnostic results and interpretation, complete problem list, recommendations, declined recommendations (if any), medications and prevention being prescribed, thorough plan and discussion, treatments or procedures performed, monitoring, follow-up/recheck instructions, and additional information using the information provided. State where each vaccine was given. Include this signature at the bottom of the record:
Thank you for trusting us with your pet’s care!
Best regards,

**Note:** The record is written using a dictation service and to please excuse any spelling and grammatical errors at the bottom of the record.

Include more information and more details. Then, use the following body systems and defaults for the physical exam section, otherwise replace defaults with abnormalities provided:

Temperature:

Heart Rate:

Respiratory rate/effort:

Mucus Membranes:

Capillary Refill Time:

Hydration:

Weight:

Body Condition Score:

Behavior/Mentation:

Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.

Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.

Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).

Gastrointestinal System: Gastrointestinal system is normal.

Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.

Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.

Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).

Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.

Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.

Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.

Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.

Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.

Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.

Rectal: Not performed. No outwardly perineal abnormalities noted.

Finally, the record must include all the following information: Puppy talk:

v It is recommended to spay and neuter all pets. Small breed dogs should be spayed/neutered at about 6 months of age. Large and giant breed dogs (over 50lbs) should wait until after the 1st heat cycle in females or 12-24 months of age, pending breed. Breeding animals should be spayed/neutered after they are done with breeding (age 2-7 years) in order to decrease likelihood of developing certain cancers, prostatic problems in males, and pyometra (life threatening uterine infection) in females.

o Giant breed dogs and large breed dogs with predisposition to gastric dilation and volvulus should have a preventative surgery involving tacking the stomach.

v Vaccines- Rabies and Distemper (contains leptospirosis) vaccines are required for all dogs. Lifestyle vaccines depend on the dogs need/risk of exposure: Kennel Cough, Canine Influenza, and Lyme. Vaccines must be boostered every 2-4 weeks until a certain age in order to be effective. Yearly boosters are required thereafter.

v Prevention for heartworm, intestinal parasites, fleas, and ticks will be sent home today. Orals should be started tomorrow with a full meal, that way if they do have a reaction, we know if it is the vaccines or prevention. Preventatives are needed for all pets, including those that don't travel, come in contact with other pets, or spend much/anytime outside. Pets should be weighed monthly until they are done growing to prescribe the correct dose of prevention, and it needs to be given every 1-3 months (pending the product) lifelong.

o If you haven't already, bring in a stool sample for your pet to be tested for intestinal parasites before allowing contact with other pets. This is sent out. We receive the results the following business day and "no news is good news".

v Nutrition is a key part in ensuring healthy development of your puppy. We recommend 3 brands of food: Purina Proplan, Hill's Science Diet, and Royal Canin. These brands have recipes formulated by board certified nutritionists, have strict quality control protocols, and contain high quality ingredients. They are known to contain the necessary amount of essential fatty acids in the diet required for joint health, skin/haircoat, and neurological function. Puppies need to be fed 3 times daily until 4-6 months old. After that feeding can be reduced to 2 times daily.

o Make sure your pet is on an appropriate food for their breed, i.e., large and giant breed dogs need to be on a formula containing optimal proportions of calcium, phosphorus, and protein for bone development.

o Small breed dogs can be transitioned to adult food at 7-9 months of age. Large breed dogs can be transitioned to adult food at 12-14 months of age. When making the transition, do so slowly by mixing the puppy and adult food together over a week or 2, increasing the proportion containing the new food.

o DO NOT FEED GRAIN FREE DIETS. Dogs are omnivores and require carbohydrates. The FDA and USDA have proven a link to heart disease.

v We recommend acquiring pet insurance for your puppy as soon as possible. Waiting will result in the insurance company to not cover any problems that arise prior to signing up.

o We recommend Trupanion, Embrace, and Pet's Best

v It is important to begin working with your pet by getting them accustomed to having their feet touched/nails trimmed, mouth handled/teeth brushing, and ears looked at/cleaned to avoid aversions. Behaviors both positive and negative are instilled in dogs by 12 weeks old. Socialization, including exposure to people, places, sounds, etc. to prevent aggression and anxiety needs to be started around 3 weeks old and is completed by 16 weeks old. Puppy classes are a great way to get your puppy socialized.

o Be mindful, your puppy has not completed its vaccine series by this time and is susceptible to infectious diseases. Take care who your puppy comes into contact with.

Vaccine reactions: BEWARE of any vomiting, diarrhea, facial swelling hives, fever, severe pain, or profound lethargy. These are symptoms of a possible vaccine reaction and we should be notified immediately. More common/less severe side effects may include sleepiness, decreased appetite, mild soreness at injection site, sneezing, or a temporary small lump at injection site.

Feline Templates

Cat Report

**NAME:**
**PATIENTID**:
**FULLNAME:**
**ID:**
PHONENUMBER:
SPECIES:
BREED:
AGE:
SEX:
ALLERGIES:
**MEDICALALERT:**

**Physical Exam Feline- Exam Date:**

**Chief Complaint today:**
Technician history:
DVM notes:
Behavioral concerns (including changes since last visit): None
**VITAL SIGNS:**
Temperature (F):
Pulse rate (beats/min):
Respiratory rate breaths/min):
Capillary refill time (s):
Weight (lbs):
Pain score: /4
Source of pain:
Were signs of fear, anxiety and/or stress present during examination and if so, what was helpful in reducing the signs?
Body condition score (1-9):
Muscle Condition Score: Normal muscle mass/Mild muscle loss/Moderate muscle loss/Severe muscle loss
Ideal weight (if current weight is not ideal): (lbs) recommended daily calorie intake
Continue feeding to maintain current body condition
Current diet (include treats and food intended for human consumption) and frequency of feeding:
Current medications (include parasite prevention, supplement(s), non prescription and prescription
medications:
Microchip: Yes/No/Declined (1 in 3 pets goes missing during its lifetime)

**Environment:**
Family not present at time of examination, so complete environmental history not able to be discussed: YES/NO
Indoor only: Yes/NO
Indoor mostly with access to a screened porch or fenced yard? No/Yes
Indoor/outdoor: YES/NO
Does pet roam outdoors with exposure to other/unknown cats? No/Yes
Which flea, tick and heartworm prevention is being used?
Last date administered:
Which wildlife is pet exposed to?
When was pet last tested for FeLV, FIV and/or heartworm disease?
Are there other pets in the household No Yes How many and what kind(s)?
Where does pet stay when family is away from home?
Does or has pet pet travel(ed)? No/Yes Where:
What veterinary insurance plan are you using? None/Embrace/Nationwide/Trupanion/VPI/Other
What daily dental care regime are you following? Brushing/Dental wipes/Dental chews/Water additive/dental diet/None
If condition present, please either describe; classify as mild, moderate or severe; or classify on customary
scale

**CIRCULATORY**
Normal rate: Present/Absent
Normal rhythm: Present/Absent
Synchronous pulses: Present/Absent
Murmur: Present/Absent Grade 1/Grade 2/Grade 3/Grade 4/PMI:
Other:

**RESPIRATORY SYSTEM**
Normal BV (lung) sounds: Present/Absent
Nasal discharge: Present/Absent
Coughing: Present/Absent
Crackles/wheezes: Present/Absent
Other:

**ORAL CAVITY**
Moist mucous membranes of normal color and capillary refill time: Present/Absent
Halitosis ("bad breath"): Present/Absent
Gingivitis Mild Moderate: Severe/Absent
Calculus: 0/1/2/3/4
Missing dentition: Absent/Present Site:
Worn/fractured dentition: Absent/Present Site:
Oral masses, inflammation, ulceration or abnormal pigmentation Absent/Present Site:
Lesion(s) of tongue, hard palate, soft palate: Absent/Present Site:
Foreign body: Absent/Present Site:
Other:

**EYES**
Menace (inconsistently present in cats): Left present/Left absent/Right present/Right absent
Positive direct and consensual PLRs: Left present/Left absent/Right present/Right absent
Lid lesions: Left present/Left absent/Right present/Right absent
Discharge: Left present/Left absent/Right present/Right absent
Conjunctival lesion(s): Left present/Left absent/Right present/Right absent
Corneal lesion(s): Left present/Left absent/Right present/Right absent
Nuclear sclerosis :Left present/Left absent/Right present/Right absent
Cataract or lesion(s) of lens: Left present/Left absent/Right present/Right absent
Anterior segment lesion(s): Left present/Left absent/Right present/Right absent
Lesion(s) of fundus: Left present/Left absent/Right present/Right absent
Fluorescein stain: Left positive/Left negative/Right positive/Right negative
Other:

**EARS**
Pinna lesion(s): Left present/Left absent/Right present/Right absent
Odor: Left present/Left absent/Right present/Right absent
Discharge: Left present/Left absent/Right present/Right absent
Inflammation canals: Left present/Left absent/Right present/Right absent
Visible tympanic membrane(ear drum): Left present/Left absent/Right present/Right absent
Other:

**Cytology**: No Microorganisms
Yeast:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+
Cocci Bacteria:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+
Rod Bacteria:
AS( left): 1+/2+/3+
AD (right): 1+/2+/3+

**ABDOMEN**
Distension: Present/Absent
Organomegaly: Present/Absent
Mass(es): Present/Absent
Appropriate bowel wall thickness: Present/Absent
Other:

**UROGENITAL**
Normal shape and size of kidneys if palpable: Present/Absent
Palpation of urinary bladder concerning for stones or bladder wall thickening: Present/Absent
Normal conformation of external genitalia: Present/Absent
Mammary masses: Present/Absent
Other:

**RECTUM**
Mass(es) of rectum and/or urethra: Present/Absent
Normal size and position of pelvic canal: Present/Absent
Anal sac distension / disease: Present/Absent
Anal sacs expressed: Left/Right
Digital rectal examination not performed, but external palpation unremarkable:
Other:

**MUSCULAR SYSTEM**
Lameness: Present/Absent
Normal gait and posture: Present/Absent
Pain: Present/Absent
Other:

**LYMPH NODES**
Lymph node enlargement: Present/Absent
Site of enlargement(s) if present

**NERVOUS SYSTEM**
Appropriate mental status and behavior: Present/Absent
Normal strength, symmetry and coordination: Present/Absent
Normal placement: Present/Absent
Normal cranial nerves (if performed): Present/Absent
Normal spinal reflexes (if performed): Present/Absent
Other:

**SKIN**
Odor: Present/Absent
Hairloss: Present/Absent Site:
Seborrhea (flaking): Present/Absent Site:
Fleas: Present/Absent
Ticks: Present/Absent
Subcutaneous/cutaneous masses : Present/Absent Site:
Papules: Present/Absent Site:
Pustules: Present/Absent Site:
Epidermal collarettes: Present/Absent Site:
Erythema: Present/Absent Site:
Pruritus (itching) scale: Site :
Other:

**Cytology**: No Microorganisms
Yeast:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+
Cocci Bacteria:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+
Rod Bacteria:
Site: Grade: 1+/2+/3+
Site: Grade: 1+/2+/3+

**Scrape:**

**DIAGNOSTICS**
Fecal centrifugation /float: No ova or parasites/Parasites/ Recommended, but declined
Fecal cytology: Normal/Abnormal/Recommended, but declined
Fecal collection cup sent home:
Fecal Dx to lab pending - we will email results once they are available:
FELV: Negative/Positive
FIV: Negative/Positive
Feline heartworm: Not detectable/Positive/Recommended, but declined
Complete blood cell count: All values within normal reference ranges/Values outside of normal reference ranges/Recommended, but declined/Basic panel to lab pending
Serum chemistry panel All values within normal reference ranges/Values outside of normal reference ranges/Recommended, but declined/Basic panel to lab pending - we will email results once they are available

Urinalysis: Normal/Abnormality(ies) / notes: /pending/ Recommended, but declined

Feline pancreatic lipase: Normal (pancreatitis highly unlikely)/Abnormal (consistent with possible pancreatitis)
Radiographs: Normal/Findings: /Recommended, but declined
T4: Low/Normal/High
Pending tests:
Other:

**VACCINATIONS** Site Declined
FVRCP: #1/#2/#3/Triennial Due again: at 6 months/3 years , Site: right forelimb ,Declined:
Rabies: yes/No. Due again: 1 year, Site: RIGHT hindlimb, Declined:
Feline leukemia #1/#2 Due again: 1 year/2 years Site: LEFT hindlimb
Declined vaccinations: Feline leukemia (indoor only/minimal risk)

**TENTATIVE OR DEFINITIVE DIAGNOSES:**

**INSTRUCTIONS/RECOMMENDATIONS:**
Please take advantage of our comprehensive oral health assessment and treatment recommendation plan which
includes anesthesia and electronic anesthesia monitoring, IV catheter placement and fluids during procedure,
full-mouth x-rays, dental scaling, sub-gingival curettage (cleaning below the gumline just as our dentist does
for us) and dental polishing. Dental/periodontal disease is the most commonly diagnosed disease in cats,
affecting 75% of feline patients over the age of 2 years. Oral disease can affect overall health, so routine
assessment and preventative care is absolutely essential!
Daily dental care (brushing preferred, Feline Greenies, Healthy Mouth Rinse (www.healthymouth.com), other VOHC approved oral care products)
Continue monthly parasite protection (heartworm disease, fleas/ticks, intestinal parasites)...even indoor only cats can acquire heartworms...and fleas can carry potentially fatal disease(s)! Monthly Revolution is
imperative for your pet's overall health!
Specific food recommendation:

**TREATMENTS/PROCEDURES:**

**PRESCRIPTIONS** (all instructions clearly printed on labels):

**NEXT EXAM:**

Adult Feline Wellness

**Consultation history:**
Date:

**POST APPOINTMENT INSTRUCTIONS:**

Meds:

Recheck:

Other notes (dc notes, bill, food, etc):

RTG?:

**History:** Routine examination for vaccinations. Doing well at home. Eating and drinking normally. No owner or patient concerns. Good E level/appetite. No v/d/c/s. Normal urine/thirst/feces. **Staff initials:**

**Anal gland expression?**

**Nail trim?**

**Current meds/deworming:**

**Current diet (grain-inclusive? legume-free?):**

**Temperature:**. C (aural)
**Pulse:** bpm
**Respiration:** brpm
**Body Condition Score:** BCS 5/9
**Attitude:** BAR, friendly
**Oral cavity/MMs:** MMs pink, moist, CRT<2 sec
**Teeth:** NSF
**Cardiovascular:** No murmur or arrhythmia auscultated
**Respiration:** Clear in all fields, no crackles or wheezes
**Lymph nodes:** Peripheral lymph nodes normal size and symmetrical
**Eyes:** Clear
**Ears:** Clean
**Nasal:** NSF
**Abdominal Palpation:** Soft and comfortable throughout
**Musculoskeletal:** NSF
**Genitourinary:** NSF
**Integumentary:** NSF
**Rectal:** NSF
**Nervous:** NSF

**Diagnostics:**

**CBC:** n/a
**CHEM/LYTES:** n/a
**Radiographs:** n/a
**Cytology:** n/a

**Vaccinations:**

FVRCP LH SQ @ stifle (Purevax serial #, expiration: ) - **repeat in 1 year/ 3 years**
FeLV LF SQ @ elbow (Purevax serial #, expiration:) - **repeat in 1 year**
Rabies RH SQ @ stifle (Defensor3 serial #, expiration:) - **repeat in 1 year/3 years**

**Treatment Plan/ Recommendations/ Medications to go home:**

Discussed PE findings and potential vx reactions; no vx 100% protective
Recommend deworming
Recommend grain inclusive, low legume based diet.
Recommend flea/tick prevention, Recommend heartworm prevention

Kitten Booster

Write a formal and very detailed medical record for a patient including the relevant history, physical exam, diagnostic results and interpretation, complete problem list, recommendations, declined recommendations (if any), medications and prevention being prescribed, thorough plan and discussion, treatments or procedures performed, monitoring, follow-up/recheck instructions, and additional information using the information provided. State where the vaccines were given. Include this signature at the bottom of the record:

Thank you for trusting us with your pet’s care!

Best regards,

**Note:** The record is written using a dictation service and to please excuse any spelling and grammatical errors at the bottom of the record.

Include more information and more details. Then, use the following body systems and defaults for the physical exam section, otherwise replace defaults with abnormalities provided:

Temperature:

Heart Rate:

Respiratory rate/effort:

Mucus Membranes:

Capillary Refill Time:

Hydration:

Weight:

Body Condition Score:

Behavior/Mentation:

Ears: Both the ear canal and pinna are normal. Tympanic membrane (ear drum) is normal and seems to hear fine.

Eyes: Eye(s) are normal. The eyeballs, eyelids and associated structures appear normal. Appears to have normal vision.

Abdominal Palpation: Abdominal palpation is normal. This means the kidneys, intestines, liver and other abdominal organs that are palpable are normal (no masses, lumps, fluid, pain).

Gastrointestinal System: Gastrointestinal system is normal.

Heart/Circulatory System: Heart is normal. The heart sounds are clear with no murmurs or arrhythmia heard. The pulses are normal.

Lungs/Respiratory System: Lungs sound normal with no fluid, crackles or wheezes. The trachea sounds normal and palpates normal.

Lymph Nodes/Thyroid gland: External lymph nodes (submandibular, pre-scapular, axillary and popliteal) all palpate normally. There are no abnormal structures associated with the thyroid gland (cats).

Mouth/Teeth: Oral examination is normal. There is no evidence of tartar on the teeth or gum disease.

Musculoskeletal: Muscles are in good condition. The skeleton is observed to be normal with no lameness noted.

Nervous System: Nervous system is normal. There are no observable defects in the nerves, spinal cord or brain function.

Nose/Throat: Nose and throat are normal. Air flows freely through nostrils, no discharge is noted and there are no difficulties with vocalizing or swallowing.

Skin/haircoat: Haircoat and skin are normal. The fur is shiny with a soft texture. There are no signs of parasites or inflammation of the skin.

Urinary/Genital Systems: Urogenital system is normal. The urinary system is functioning normally. The reproductive organs examined are normal.

Rectal: Not performed. No outwardly perineal abnormalities noted.

Finally, the record must include all the following information: Kitten Talk

v It is recommended to spay and neuter all pets. Cats should have this procedure performed by 4-6 months old to prevent unwanted litters, wandering behavior, urinating in the home, and certain illnesses/cancers.

v Vaccines- Rabies, Feline Distemper, and Feline Leukemia are considered core vaccines.

o Rabies is given after 12 weeks old, preferably closer to 16 weeks old, then every 1-3 years.

o Feline Distemper contains rhinotracheitis (herpes), calicivirus, panleukopenia. It can be started as early as 4 weeks of age and must be given every 3-4 weeks until 18-20 weeks old. Then, boostered one time 6 months later. And finally, every 1-3 years lifelong.

o Feline Leukemia is started after 12 weeks of age, boostered one time 3-4 weeks later, then every 2 years thereafter. For cats that are strictly indoors, this vaccination is considered a lifestyle vaccine after 1 year old. Kittens need to have a negative FIV/FeLV test prior to vaccination.

o PLEASE TAKE NOTE CATS ARE AT RISK FOR INJECTION SITE TUMORS RELATED TO VACCINATION. Incidence is rare, approximately 1 in 10,000 to 30,000.

v Prevention for heartworm, intestinal parasites, fleas, and ticks will be sent home today. Preventatives are needed for all pets, including those that don't travel, come in contact with other pets, or spend time outside. Pets should be weighed monthly until they are done growing to prescribe the correct dose of prevention, and it needs to be given every 1-2 months (pending the product) lifelong.

o If you haven't already, bring in a stool sample for your pet to be tested for intestinal parasites before allowing contact with other pets. This is sent out. We receive the results the following business day and "no news is good news".

v Nutrition is a key part in ensuring healthy development of your kitten. We recommend 3 brands of food: Purina Proplan, Hill's Science Diet, and Royal Canin. These brands have recipes formulated by board certified nutritionists, have strict quality control protocols, and contain high quality ingredients. They are known to contain the necessary amount of essential fatty acids in the diet required for joint health, skin/haircoat, and neurological function. Kittens need to be fed 3-4 times daily until 4-6 months old. After that feeding can be reduced to 2 times daily. The average cat should be offered no more than ½ cup of dry food total daily, or less if adding in canned food too (approximately 200 calories/day).

o Cats can be transitioned to an adult diet at 6 months old. When making the transition, do so slowly by mixing the kitten and adult food together over a week or 2, increasing the proportion containing the new food.

o DO NOT FEED GRAIN FREE DIETS. The FDA and USDA have proven a link to heart disease.

o It is recommended to feed cats a diet containing canned and dry food. The combination can help prevent plaque, urinary problems, and kidney dysfunction.

v We recommend acquiring pet insurance for your kitten as soon as possible. Waiting will result in the insurance company to not cover any problems that arise prior to signing up.

o We recommend Trupanion, Embrace, and Pet's Best

v It is important to begin working with your pet by getting them accustomed to having their feet touched/nails trimmed, mouth handled/teeth brushing, and ears looked at/cleaned to avoid aversions. Enrichment including scratching posts, cat trees, and puzzle toys should be provided.

FeLV vaccine: Given SQ distally left hind limb.

FVRCP vaccine: Given SQ right shoulder.

Feline Rabies vaccine: Given SQ distally right hind limb.

Vaccine reactions: BEWARE of any vomiting, diarrhea, facial swelling hives, fever, severe pain, or profound lethargy. These are symptoms of a possible vaccine reaction and we should be notified immediately. More common/less severe side effects may include sleepiness, decreased appetite, mild soreness at injection site, sneezing, or a temporary small lump at injection site.

Equine Templates

Equine SOAP

**Date:**
**Veterinarian:**
**Charges:**
**Owner:**
**Alternate Contact:**
**Animal Identification:**

**History/Previous Treatment:**

**Presenting Complaint:**

**Physical Examination:**
T: (F/C) HR: bpm RR: /min
Attitude: BCS:
Appetite: Normal/Partial/Absent Duration:

**Significant Findings:**

**Assessment:**

**Treatment Plan:**

**Instructions to Owner:**
1- Product:
Amount:
Route:
Frequency:
Duration:
2- Product:
Amount:
Route:
Frequency:
Duration:

**Withdrawal Instructions:**

Date:
Veterinarian's Signature:

Equine Dentistry

**[History]**
-Previous dental issues:
-Current symptoms:
-Feeding habits:
-Problems with bit:

**[Physical Exam]**
-General appearance:
-Jaw alignment:
-TMJ palpation:
-Head palpation:
-Bars palpation:
-Presence of cheek ulcers:

-Central Incisor (101):
-Intermediate Incisor (102):
-Corner Incisor (103):
-Canine (104):
-Wolf Tooth (Premolar 1, if present) (105):
-Premolar 2 (106):
-Premolar 3 (107):
-Premolar 4 (108):
-Molar 1 (109):
-Molar 2 (110):
-Molar 3 (111):

-Central Incisor (201):
-Intermediate Incisor (202):
-Corner Incisor (203):
-Canine (204):
-Wolf Tooth (Premolar 1, if present) (205):
-Premolar 2 (206):
-Premolar 3 (207):
-Premolar 4 (208):
-Molar 1 (209):
-Molar 2 (210):
-Molar 3 (211):

-Central Incisor (301):
-Intermediate Incisor (302):
-Corner Incisor (303):
-Canine (304):
-Premolar 2 (306):
-Premolar 3 (307):
-Premolar 4 (308):
-Molar 1 (309):
-Molar 2 (310):
-Molar 3 (311):

-Central Incisor (401):
-Intermediate Incisor (402):
-Corner Incisor (403):
-Canine (404):
-Premolar 2 (406):
-Premolar 3 (407):
-Premolar 4 (408):
-Molar 1 (409):
-Molar 2 (410):
-Molar 3 (411):

-Diastema:

**[Diagnostic Tests]**
-Radiographs:
-Other tests:

**[Procedures]**
-Sedation:
-Extractions:
-Other procedures:

**[Treatment Plan]:**
-Medications prescribed:
-Follow-up appointments:
-Dietary recommendations:

Avian Templates

Exotic Template 1

**Chief Complaint:**
- Reason for visit

**History:**
- Detailed history of the presenting complaint
- Previous medical history
- Diet
- Environment
- Behavior

**Physical Examination:**
- General appearance
- Weight
- Body condition score
- Feather condition
- Behavior/neurological status
- Eyes, ears, nose, throat
- Beak, oral cavity
- Skin/feathers
- Musculoskeletal system
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Urogenital system
- Cloaca

**Diagnostic Tests:**
- Test name and result
- Additional tests if needed

**Assessment:**
- Summary of findings
- Differential diagnoses

**Plan:**
- Treatment plan
- Any prescribed medications
- Client education
- Follow-up appointments

**Notes:**
- Any additional observations or plans
Physical Examination:
- General appearance
- Weight
- Body condition score
- Feather condition
- Behavior/neurological status
- Eyes, ears, nose, throat
- Beak, oral cavity
- Skin/feathers
- Musculoskeletal system
- Cardiovascular system
- Respiratory system
- Gastrointestinal system
- Urogenital system
- Cloaca

**Diagnostic Tests:**
- Test name and result
- Additional tests if needed

**Assessment:**
- Summary of findings
- Differential diagnoses

**Plan:**
- Treatment plan
- Any prescribed medications
- Client education
- Follow-up appointments

**Notes:**
- Any additional observations or plans

Exotic Template 2

**Avian Background Information:**

Code Status:
Is this a referral?: Regular DVM / Hospital:
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Do you use any cleaners/sprays/candles/Teflon products/non-stick cookware/ or cook around the patient?:
Other birds in the house?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used if any?:
Do you use a UVB Bulb? What type? Distance from the pet?:
How often is the UVB bulb changed?:
Diet:
Eating/drinking normally?:
Any supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Sneezing, Vomiting or Regurgitation?:
Is your pet lethargic or quiet?:
Behavior normal? Perching? Active?:
Flighted?:
If a Female-Does the patient lay eggs?:
Is your pet on any medications?:
Adverse Medication / Reactions:
When were the last doses administered?:
Are any refills needed today?:

**Attending Veterinarian:**

**Presenting complaint and duration:**
**Current History:**

**Previous Medical History:**

Husbandry changes discussed:
Husbandry changes recommended today:

**Objective:**

Vital Signs:
Heartrate:
Respiration:
Weight: Previous weight: (kg)/ Date:
Flighted:
Mentation:
Characterize Droppings:
Perching normal position:
Nurse:

**Examination Findings:**

Body Condition Score: /5
Muscle Condition Score: /3
Pain Scale: 0/4
ASA: 0-4

Eyes, Ears, Nose, Throat: Fundic normal OU, normal cornea, lenses and iris OU; Clear AU; Nares clear bilaterally, no discharge or lesions

Oropharyngeal: Normal beak occlusion, normal keratin, no lesions or defects; normal tongue; choana clear with normal/ABNORMAL choana papillae, mm pink/pigment and moist

Cardiovascular: normal rate and rhythm, normal ulnar refill and volume

Respiratory: Normal RR/RE, clear on auscultation over dorsum/lungs, air sacs clear in all fields, no rubbing or fluid noted

Abdomen / GI: Soft concave coelom, no masses or lesions palpable

Vent Exam: mucosa clear on eversion, pink moist, no polyps or lesions; normal perivent

Urogenital: normal urates, Sex UNKNOWN/MALE/FEMALE

Musculoskeletal: normal wing snap, normal grip strength, normal/ABNORMAL keel muscle condition

Integumentary: NORMAL/ABNORMAL feather quality, normal skin of face, head and pes, normal nails

Nervous System: normal perch position, normal posture, no weakness of pelvic or thoracic limbs

Behavior: N/A

**Labs + Diagnostics:**

**Assessment:**

**Current Assessment/Differentials:**

**Chronic health concerns:**

**Prognosis:**

**Historical Problem list/Visits:**

**Plan:**

**Medications:**

Other Animals

Farm Animal SOAP

**Date:**
**Veterinarian:**
**Charges:**
**Owner:**
**Alternate Contact:**
**Animal Identification:**

**History/Previous Treatment:**

**Presenting Complaint:**

**Physical Examination:**
T: (F/C) HR: bpm RR: /min
Weight/Body Condition:
Attitude: BCS:
Appetite: Normal/Partial/Absent Duration:
Reproductive Status: Pregnant/Open/Fresh/Bred/Immature

**Significant Findings:**

**Assessment:**

**Treatment Plan:**

**Instructions to Owner:**
1- Product:
Amount:
Route:
Frequency:
Duration:
2- Product:
Amount:
Route:
Frequency:
Duration:

**Withdrawal Instructions:**
Milk withdrawal: Hrs / Days
Meat withdrawal: Hrs / Days

Milk from this animal, taken at the am/pm milking, may go into the tank on .
if administered as prescribed.
Milk from this animal must be subject to inhibitor Testing before the milk may go into tank.
The recommended date for Inhibitor Testing is the am/pm of .
This animal may be shipped for slaughter on .

Date:
Veterinarian:

Reptile SOAP

History:

Code Status:
Is this a referral?
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Do you use any cleaners/sprays or other chemicals around the patient?:
Other reptiles in the house?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used?:
Do you use a UVB Bulb? What type? Distance from the pet?:
How often is the UVB bulb changed?:
What is the temperature in the cage?
How is this monitored?:
High Temp:
Low Temp:
What is the humidity in the cage?
How is this monitored?:
Diet:
Eating/drinking normally?:
Any calcium/vitamin supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Sneezing, Vomiting or Regurgitation?:
Is your pet lethargic or quiet?:
Behavior normal?:
If Female-Has the patient laid eggs or given birth ?:
When was your reptile's last shed? Was it normal?:
Is your pet on any medications?:
Adverse Medication / Reactions:
When were the last doses administered?:
Are any refills needed today?:

Attending Veterinarian:

Presenting complaint and duration:

Current History:

Any previous health issues?:
Previous Medical History:

Husbandry changes discussed:
Husbandry changes recommended today:

Nurse/Date:
Objective:

Heartrate:

Respiration:

Weight: Previous weight (kg)/ Date:

Mentation:
Characterize Feces:
Normal body positioning/strength:
Hydration Status:
Nurse:

Examination Findings:

Body Condition Score: /5
Muscle Condition Score: /3
Pain Scale: 0/4
ASA: 0-4

Eyes, Ears, Nose, Throat: normal corneas OU, normal fundic OU, no periocular swelling or lesions OU; Tympanum normal and intact AU, no bulging or discharge; Nares normal bilaterally, no discoloration or discharge; No neck or swelling or masses noted.

Oropharyngeal: Pink/PIGMENTED moist mucous membranes; Saliva curtain THICK/ABSENT; No/hypersalivation present; No masses or lesions within other oropharynx, no plaques; No obvious aneurysms noted, no tissue swelling. Beak is Normal/ABNORMAL.

Cardiovascular: normal on Doppler

Respiratory: Normal RR/RE, no open mouth breathing, no discharge, no distress or accessory muscle breathing noted. Recovered quickly after handling.

Abdomen / GI: Coelomic palpation is normal/ABNORMAL; No masses or lesions palpable; Normal/ABNORMAL material passed on defecation; Vent is pink/PIGMENTED, moist with no lesions or masses.

Vent Exam: Pink/Pigmented mucosal on eversion, no masses or lesions; NO/Hemipenal plugs noted. No substrates noted within the vent.

Urogenital: Urates/urine normal/ABNORMAL/not observed during exam; FEMALE/MALE/SEX UNKNOWN

Musculoskeletal: Normal strength, ambulates normally/ABNORMALLY; Normal grip/elevation of body from surfaces, no weakness.

Integumentary: Normal/ABNORMAL carapace and plastron, no pitting/ulceration noted; No/retained shed or thermal burns, bite wounds or other dermal lesions; Normal/ABNORMAL scales

Nervous System: Mentally appropriate, normal pain perception, normal ambulation

Other: N/A

Behavior: N/A

Labs + Diagnostics:

Assessment:

Current Assessment/Differentials:

Chronic health concerns:

Prognosis:

Historical Problem list/Visits:

Plan:

Therapeutic Plan:

Medications:

Meds Filled/Nurse [ n/a ]

Meta-Plan:

Small Mammal SOAP

Subjective:

History:

Small Mammal Background Information:

Code Status:
Is this a referral?:
Pet Insurance: Is the patient protected by an insurance plan?:
How old is your home?:
Other pets in the house?:
Behavior: Has the patient had any aggression- or fear-based incidents in the past?:
Does he/she go outdoors at all?:
Does he/she live in an enclosure?:
What kind of substrate/bedding is used?:
What is the temperature in the cage (Hedgehogs)?
How is this monitored?:
Diet:
Eating/drinking normally?:
Any supplements used?:
Brand? Type:
Normal droppings/normal amount?:
Coughing, Sneezing, Nasal Discharge?:
Vomiting (Ferrets only):
Is your pet lethargic or quiet?:
Behavior normal?:
Is your pet on any medications?:
When were the last doses administered?:
Adverse Medication / Reactions:
Are any refills needed today?:

Attending Veterinarian:

Presenting complaint and duration:
Current History:

Any previous health issues?:
Previous Medical History:

Husbandry changes discussed:
Husbandry changes recommended today:

Nurse/Date:

Objective:

Vital Signs:

Heartrate:

Respiration:

Capillary Refill Time:

Temperature:

Weight: Previous weight (kg)/ Date:

Mentation:
Characterize Feces/Fecal Pellets:
Hydration status:
Nurse:

Labs + Diagnostics :

Assessment:

Current Assessment/Differentials:

Chronic health concerns:

Prognosis:

Historical Problem list/Visits:

Plan:

Therapeutic Plan:

Medications:

Meds Filled/Nurse

Meta-Plan:

Custom Note Template Library

A collection of templates you can use and modify.

Glossary

How to use

General Templates

General Workup

Initial Command

Procedure

Detailed Discharge

Euthanasia

Spay Surgery

Controlled Substances

Chiropractic

Rehab Exam Discharge Instructions

Physical Therapy

Integrative Medicine

Blood Work Call Back

Sick Pet

Wellness

Hospitalized Patient

Record with Discharge

Ultrasound

Radiographs

Dental Chart

Canine Templates

Adult Canine Wellness

Dog Spay Surgery

Canine Dental Numbered Chart

Dog Neuter Surgery Report

Dog Neuter Surgery

Puppy 8 weeks History Appointment

Canine Vaccine Plan

Puppy Booster

Feline Templates

Cat Report

Adult Feline Wellness

Kitten Booster

Equine Templates

Equine SOAP

Equine Dentistry

Avian Templates

Exotic Template 1

Exotic Template 2

Other Animals

Farm Animal SOAP

Reptile SOAP

Small Mammal SOAP