This Action Items Template helps veterinarians and clinic staff efficiently document crucial patient information, owner consultations, and follow-up care plans. It addresses the challenge of capturing detailed instructions and treatment steps while managing active patient interactions, ensuring nothing is missed.
Patient & Owner Information
Buddy
Enter the full name of the animal patient.Canine / Golden Retriever
Specify the animal's species and breed.Jane Doe
Provide the full name of the pet owner.(555) 123-4567
Record the primary contact number for the owner.Chief Complaint & Assessment
Lethargy, decreased appetite for 2 days, occasional vomiting.
Summarize the primary reason for the patient's visit.TPR WNL, BCS 4/9, mild abdominal tenderness on palpation, no fever.
Document key findings from the initial physical examination.Gastritis, foreign body, pancreatitis.
List potential diagnoses based on current findings.Diagnostic Plan & Results
CBC, Chemistry Panel, Abdominal X-rays.
Outline the diagnostic tests suggested to the owner.Owner consented to CBC and X-rays only.
Note which diagnostics were approved by the owner.CBC: mild leukocytosis. X-rays: no foreign body, increased gas in GI.
Summarize significant results from completed tests.Treatment Plan & Medication
IV fluids 20ml/kg over 1 hr, Cerenia 1mg/kg SQ.
Detail treatments administered during the clinic visit.Metronidazole 10mg/kg PO BID x 5 days, Famotidine 0.5mg/kg PO SID x 5 days.
List all medications prescribed for home administration.Metronidazole: 'Give 1 tablet by mouth every 12 hours.' Famotidine: 'Give 1/2 tablet by mouth every 24 hours.'
Clearly state dosage, frequency, and route for each medication.Bland diet (boiled chicken & rice) for 3-5 days.
Specify any dietary changes or restrictions.Owner Communication & Follow-up
Discussed medication administration, diet, and signs of worsening condition (lethargy, vomiting, diarrhea).
Document all key instructions and advice given to the pet owner.Owner concerned about cost of diagnostics; provided estimate and alternative options.
Note any specific questions or concerns raised by the owner and how they were addressed.Recheck in 3 days or sooner if condition worsens. Bloodwork recheck in 2 weeks.
Clearly define the next steps and timeline for follow-up care.Yes, scheduled for [Date] at [Time] with Dr. Smith.
Indicate if a follow-up appointment has been booked.How to Use This Template
- Open the 'Action Items Template' in CraftNote when starting a new patient consultation or follow-up.
- Use voice-to-text to quickly fill in fields like 'Chief Complaint' and 'Initial Assessment Findings' while examining the patient.
- During owner consultations, use the 'Instructions Provided to Owner' field to document key advice and ensure clarity.
- Share the completed Action Items directly with owners via email or print to provide a clear, written record of care and follow-up.
- Utilize the 'Follow-up Plan' field to set reminders within CraftNote for future actions or recheck appointments.
Customization Tips
- Duplicate this template for specific case types (e.g., 'Surgical Action Items' or 'Wellness Visit Action Items') and pre-fill common procedures or recommendations.
- Add a 'Pre-Op Instructions' section for surgical cases, detailing fasting requirements and medication cessation, to ensure owners are fully prepared.
- Integrate a 'Client Education Resources' field where you can quickly link to relevant articles or videos for specific conditions discussed during the visit.