This section is supposed to supply veterinary technicians with guidelines for writing the patient care plan portion from the veterinary medical record. As there isn‘t any standardized format for writing a veterinary care plan, the listed principles are just one example of the way in which a care plan can be formulated. These principles happen to be adapted from materials developed by veterinary technology instructor / academic advisor and veterinary instructional technologist Veterinary Technology Program.
Veterinary medical records should be complete, accurate, orderly, and legible and should provide a description of that which was done, when, by whom, why, how, and where. Because they‘re legal documents, certain conventions should be followed when recording information. Of concern are legal issues surrounding documentation.
A patient’s record is really a compilation of written information, reports, and communication regarding the patient’s care, and it also should render a full understanding from the patient’s health status.following parts:
Rationale for interventions
Continued patient reassessment
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