What should be documented following a physical examination of an animal?

Documenting findings, diagnosis, and treatment plan after a physical examination of an animal is essential for several reasons. This comprehensive documentation ensures that all pertinent information regarding the animal's health status is recorded. It creates a clear, systematic record that can be referred back to in future visits, allowing veterinarians and veterinary staff to track the animal's health over time, monitor progress, and make informed decisions about ongoing care.

Including findings of the examination captures any abnormalities or noteworthy observations, while the diagnosis provides clarity on the health issue identified. The treatment plan outlines the proposed actions to address the diagnosis, such as medications, further testing, or follow-up visits, ensuring that all team members involved in the animal's care have a consistent plan to follow.

In contrast to this thorough approach, documenting only the breed and age of the animal lacks depth and fails to contribute to the animal's medical record in a meaningful way. A detailed history of the owner, while important, is not the primary focus immediately following a physical examination and can be collected in conjunction with patient records. Simply noting the total cost of treatment disregards the necessary clinical information that guides care decisions and follow-up, which is crucial for effective veterinary practice.