Rural Veterinary Experience, Teaching, and Service
An Introduction to our Records

The importance of accurate records cannot be understated.  A student or group of students will be assigned each evening to review the records for completeness and accuracy.  They then will be used as a part of the rounds process.  We will review the records and discuss what entries could have been made differently.  Our goal is not to criticize, but to use the records as a tool for teaching.   They will also be used to complete the daily tally.

Records should be clear, concise, and complete, but not redundant. Be specific.  If you have no history, write “history unavailable,” and include why, “Owner not present for exam,” “horse found on side of road”, etc.  If a PE is not performed, circle this on the record and explain why.   

Our records are very concentrated. Each section of the records has its own color.  This system was designed to help you find the section in which you need to write. 


Please pay particular attention to the following points

The client must sign the form
If a client has multiple forms they must sign each form
Notes are a very important part of the records, please be thorough

Fill the form out as you complete the work (record surgical and anesthetic information, as well as NSAIDs and antibiotics as they are given

Each record will accommodate 3 patients and has a dental chart and space for additional notes and prescriptions on the first page; the different sections of the form are shown below. 

There are three methods of recording information on the forms.  

1.Grey type is meant to be a watermark.  Write directly over this.
2.Where multiple possibilities are listed in black type, circle all applicable  information
3.Write in blank spaces

Yellow--Patient information: patient number, weight, age, markings, name, BCS

  • Patient number may not have been pre-assigned.  In these cases they may be filled out in the evening when processing the information on the records
  • Age and BCS.  DO NOT LEAVE THESE SPACES BLANK.  For age and BCS use your note cards (they are attached to the caddies and clipboards) look at the teeth, feel the pertinent points on the body and assign a number to the boxes.
  • Color-The second yellow line refers to the patient’s color(s), circle all applicable colors
  • Markings-The third yellow line refers to any white on the face or legs, circle all options that are applicable 
White—all notes are recorded here.  If you have written a complete record, anyone looking at the record will be able to tell you:

1.What the patient presented for,
2.What we found on physical exam,
3.What treatment was provided to the patient
4.Why that treatment was chosen, 
5.What the prognosis for the patient is
6.What treatment options were discussed with the owner
7.What recommendations we discussed with the owner. 

 If you have not included all of this information on your record, it is not complete. 
Specifics of the patient history and procedure performed must be written in the notes section of the form.  The initial note will reflect what the patient presented for, when and under what circumstances the client noticed the condition.  There must be subsequent notes reflecting what, if anything, we did or did not do for the patient.  The reasons for the treatment or procedure or for why a procedure was postponed, and what recommendations we made for the patients’ future should be clear.

There is adequate room on the record for notes.  For those patients whose procedures/condition or recommendations to the owner require more space, there is a section for additional notes on the bottom of the front page. In addition, if the other notes sections were not used (surgery, anesthesia, and dental) you can utilize this space.

If a patient is anesthetized for farrier work you must record:

  • If the anesthesia due to serious pathology, patient behavior, or for the owners convenience.
  • Which foot or hooves were worked on.
  • Was the work due to a prior injury? What injury? When did it occur?
  • Was the work necessary due to a chronic laminitis?

The next section of the record describes what we did to or gave to the patient, and who was involved.  The tan and grey sections are watermark sections.  Write directly over the grey type.
Tan – Record who treated the patient.  

Grey – What we gave to the patient

  • Ivermectin, flunixin and PPG, you will record the number of mls given to the patient, as each patient will receive a different dose.  Simply write the number in the box.  Use your dosing note cards to choose an appropriate volume
  • For Tetanus Anti-Toxin, Tetanus Toxoid, Rabies and Rx you will simply X or check the box.   If a prescription was given to the patient you must record this at the bottom of the front page

Blue- What procedures were performed on the patient. All treatments are rated as a 1, 2, or 3, based on the amount of time they would take a skilled professional to complete.  Circle the appropriate procedure and number.

1 = 0-15 minutes 
2 = 15-30 minutes
3 = 30 minutes or more

Purple - Dental:  There are two parts to the dental record, a chart and a circle what you did section. 

  Each patient has a circle what you did section.  
Circle all items that apply, and specify which teeth were involved for hooks, diastemas, missing teeth and extractions.
Each record has only one dental chart.  Only chart patients who have significant dental pathology.

  • An “X” indicates a missing tooth. 
  • A “D” between two teeth indicates a diastema ( a space between teeth).  
  • An “E” over a tooth indicates an extraction
  • The mark out shown below on the upper incisors indicates that the teeth have been worn to the gums
Green - Surgery, circle: 
1. Surgery performed.
2. All items applicable to the castration that was performed.
3.All information regarding

a.the block(s) performed
b.ligatures placed

4.Surgical notes.  These should contain, but are not limited to:

a.All complications and how they were handled
b.Details pertaining to the surgery not reflected elsewhere.
i.If looking at a wound potentially connected to a synovial structure there will be an attempt to inject
 the structure to determine if it communicates with the wound. (remember to get as much history as
 possible and put it into the history portion of the record).
ii.What and how much was used for injection?
iii.What was the result? Communication, no communication…

c.Details pertaining to the cryptorchid
i.  Inguinal canal stretched?
ii. Sutured?
iii. Skin sutures?
iv.Hemicastrated previously by owner?
v.Previous scar located? On which side?

Pink & White—Anesthesia  
All anesthetic drugs are recorded in mls.  There is no need to write the word mls, it is implied.  A time is recorded below the volume.  The time of administration is VERY IMPORTANT.  Please remember to record this.

There are spaces on the record to rate/record various aspects of the anesthesia process. These include

1.Induction     (rate 1-5 see above)
2.Recovery    (rate 1-5 see above)
3.Overall Anesthetic Depth    (rate 1-5 see above)
4.Post op
a.Sedation, this can be recorded cryptically.  1 X = 1 ml xylazine… (Remember to record the time)
b.Reversal   (volume drug time) only used in cases involving IM sedation.  Very rarely used
c.Roll     (time) only done in cases involving IM sedation.  Very rare
5. Anesthesia start, end and total time.
6.Total volume of anesthetic drugs administered (this can be completed in the evening)
White-The last section of the front page contains 3 subsections.
  • Euthanasia

a.Euthanasia Recommended. Circle
b.Client signature, should we need to euthanize a patient
c.Method performed

  • Prescriptions. This is a watermark section, write directly over the grey type
  • Additional notes

If dental work beyond a routine float has been performed, turn the patient care record over, and complete the dental chart for that patient.

Patient Care Record and Discharge Instructions

IT IS VERY IMPORTANT THAT THE CLIENT GET THIS PAGE.

The patient care record contains the patient’s discharge instructions and our contact information.  In case of post operative complication the client must have the information on this page.  It is the scribe’s responsibility to complete the discharge page.  IN A BUSY CLINIC THE CHANCES OF THE CLIENT LEAVING WITHOUT THIS PAPER IS VERY HIGH UNLESS YOU FILL THE FORM OUT DURING THE SURGERY AND HAND IT TO THE CLIENT BEFORE YOU MOVE ON TO THE NEXT PATIENT.  It is more efficient to complete this as you work, (one person in your team will be the scribe, and will complete the records)  
Discuss follow up/post op care with the client during this time.

If the patient had hernia or cryptorchid surgery circle the discharge instructions on the page and discuss them with the client to ensure that they understand.
The services which the client requires should be circled on the intake sheet when the client signs in.
EQUINE CHECK IN SHEET

If the clinic will be high volume one person will be assigned to act as an intake coordinator.  This person will be responsible for completing a client check in sheet.

When the services have been provided, the care provider completes the discharge form, gives the record to the intake coordinator, and marks what services were actually provided to the patient as shown below.