This Meeting Notes Template is designed specifically for veterinarians, vet techs, and animal clinic staff. It helps overcome the challenge of documenting critical patient information and owner instructions accurately while managing examinations, ensuring clear communication, and simplifying follow-up care plans.
Patient & Owner Information
Buddy
Enter the full name of the animal patient.Canine (Golden Retriever)
Specify the animal's species and breed.Sarah Johnson, (555) 123-4567, sarah.j@email.com
Record the primary owner's name and preferred contact details.2023-10-27 10:30 AM
Log the exact date and time the consultation took place.Chief Complaint & History
Limping on right hind leg for 3 days, no known trauma.
Describe the main reason for the visit in the owner's words.Previous ACL repair on left hind leg (2 years ago). Up-to-date on vaccinations.
Note any pertinent medical history, recent changes, or prior treatments.Galliprant 20mg SID PRN for arthritis, fish oil supplement daily.
List all medications or supplements the patient is currently receiving.Royal Canin Gastrointestinal Low Fat, indoor dog, no recent travel.
Briefly describe the patient's diet and living environment.Examination Findings
TPR: 101.5°F, 120 bpm, 24 rpm. BCS 5/9. Mild discomfort on palpation of right stifle. No swelling.
Document objective findings from the physical examination.Anxious but cooperative during exam, tail tucked, avoids weight-bearing on right hind.
Record any relevant behavioral observations during the visit.Assessment & Plan
1. Right stifle lameness, rule out soft tissue injury/meniscal tear. 2. Mild dental calculus.
List potential diagnoses or a prioritized problem list based on findings.Recommend sedation for full orthopedic exam and radiographs of right stifle. CBC/Chemistry if no improvement.
Outline proposed diagnostic tests or procedures.Administer Carprofen 1mg/lb PO. Cold laser therapy session (10 min) on right stifle.
Detail treatments administered during the current visit.Discussed risks/benefits of sedation and radiographs. Owner consented to diagnostics and initial pain management. Estimated cost provided.
Summarize key points discussed with the owner and any consent obtained.Home Care & Follow-Up
Restrict activity for 7 days (leash walks only). Administer Rimadyl 50mg PO BID for 5 days. Apply cold pack to stifle 3x daily for 15 min.
Provide clear, actionable instructions for at-home care.Rimadyl 50mg tablets #10 (5 days supply).
List all medications dispensed, including dosage and quantity.Recheck in 7 days for stifle re-evaluation and suture removal (if applicable).
Specify when and why the patient needs to return for follow-up.If no improvement after 7 days, consider referral to orthopedic specialist.
Note any future actions or potential referrals.How to Use This Template
- Open the 'Veterinary Meeting Notes' template in CraftNote before starting your patient consultation.
- Fill in the 'Patient & Owner Information' as you greet the owner and review the patient's chart.
- During the examination, quickly jot down key 'Chief Complaint & History' details and 'Examination Findings' using voice-to-text or quick taps.
- After the exam, use the 'Assessment & Plan' section to structure your discussion with the owner, detailing diagnostics, treatments, and prognosis.
- Before the owner leaves, clearly document 'Home Care & Follow-Up' instructions and set reminders for future appointments.
Customization Tips
- Add a 'Surgery Specific Notes' section for pre-op checklists, intra-op findings, and post-op recovery details for surgical cases.
- Create a 'Dental Procedure Notes' section with fields for charting, scaling details, extractions, and post-dental care instructions.
- Include a 'Laboratory Results Discussion' section to document specific lab values reviewed with the owner and their implications for the patient's health.