This is how you write and send the medical notes to the pet owner.

Remember that the pet owner can read everything you write in the medical notes - always write the notes so that the pet owner understands it. Remember to focus on the main problem and to provide a clear advice. 

There is prefilled text in most info boxes - remember to erase this text - if you are not incorporating it to your notes.

How to write the medical notes:

Select issue type:

History/Anamnesis

The history should be written by you and should be based on your conversation with the pet owner. In other words, it should not be a copy of the owners ‘Issue description`.

The history should start by listing the owners main concern and signs seen by the pet owner and regarding how long they have been seen - and include the  usual assessment parameters:

- Main symptoms, duration, and onset 

- Information about general condition, appetite, thirst, urine, defecation, ongoing treatments/medicines, previous diseases as well as any known disease/conditions.

- Other relevant information 

Include a note of any in-contact animals here if this is relevant as well as a note of any foreign travels or attended competitions.

Make a note if the pet has travelled abroad recently.

History/Anamnesis example:

During the past 2 days the owner has noticed a bloody secretion from one mammary gland on the left side. The gland is enlarged compared to the other glands. Her general condition is good, and she is acting as normal with normal energy levels, appetite, urination, and defecation.

She had her last season approximately one month ago. She has previously had a false pregnancy with milk flow but she has never had blood in the secretions before.

Animal status

Information about the condition of the animal during the consultation. 

Ask to see the animal early in the meeting and describe your impression of how it is doing.  

If the consultation is a phone call, the sentence “According to owner” should be used when you describe the animals general condition and main problems. 

- State whether you have seen the animal or not 

- General condition (BAR), mucus membranes, respiration, rectal temperature, if relevant 

- The main symptoms, grading (mild/ moderate/ severe/ massive) 

- Specific description of the area in question, if relevant (location, size) 

During video calls you may be able to access mucus membranes, respiration and other parameters which may be helpful in your assessment of the animal’s health at the time. Rember that the pet owner not can assess eg abdominal pain...

The owner may be able to provide the animals current body temperature if this is relevant. 

You can use medical terms in this section as well as abbreviations if needed. 

Animal status - example:

Video consultation - and the dog is visual during consultation.

BAR and no change to general condition. Mild swelling of one mammary gland on right side and not as previously described as left side by owner. Slight blood-stained secretion. No pain noted during owners palpation of the affected gland but is feels warm compared to the other glands. Mucus membranes are pink and moist.

Main problem

In this section you list your assessment of the likely causes of these signs. In a clinic setting we would often add a diagnosis here. However, as we are not able to provide a specific diagnosis, a list of the most likely cause or causes (obs pro diagnoses) should be added to this section as well as any differentials which you would consider.

List the main problem(s)/ your differentials in the order of probability. 

It is ok to use specific veterinary terms here, but the wording should also be easily understood by the owner. We should aim to give the owner a good insight into our thoughts and understanding of the problem.

Main problem – example:

Suspicion of mastitis, but pseudopregnancy or neoplasia cannot be excluded.

Advice to pet owner

This section should contain a short summary of the main problem and the discussion followed by your conclusion, care advice and other actions (physical visit, if applicable and when), follow up appointment on AVG etc.).

It is important to be clear and precise about your recommendations and provide the owner with an action plan if things were to change unexpectedly. Therefore, if homecare is advised, then the owner should be made aware of clear time frames and any changes/signs that if seen should prompt a call to their vets.

In some cases it is a good idea to provide links to websites that offer further information on specific subjects. For example, information on local Agria web site or from another reputable source.

Make your advice a personal message to the owner, do not use medical terms or latin and use simple understandable language. 

Structure of the "Advice/message to owner":

1) Thank you for contacting the Agria! 

2) My understanding of your animal´s main problem is....  

3) Short description of the main problem/symtoms 

Use your own description or Insert advice template from the Knowledge Library and adjust them to this patient

4) Write your recommendation, e.g: 

- No treatment 

- Treatment at home 

-  Contact local clinic when they open 

-  Acute referral to clinic (use the referral function in the portal) 

Be precise in when you want the owner to contact a clinic if your recommendation is to wait and see. Specify what symptoms the owner should look for if the animal gets worse (Ex: blood in stool, lethargy)

5) End the message with a friendly, personal greeting (use the name of the animal) to show you care. Ex: Good luck with your sweet “ANIMAL NAME”! 

 Advice to pet owner - example:

Thank you for your call about “ANIMAL NAME” and her mammary swelling and discharge.

I do understand your concerns regarding the bloody discharge. There are a number of possibilities for these signs, including conditions such as mastitis, false pregnancy or even a mammary tumour. Whilst it is unlike to be the more serious of these it is important to get this ruled out and it is therefore important that she is examined by your veterinary surgeon.

As “ANIMAL NAME” is otherwise well, I recommend that you book an appointment with your usual veterinary surgery within normal opening hours tomorrow Monday.

Your vet will be able to perform a thorough clinical examination of Kerstin and therefore provide a more certain diagnosis.

In some cases, sedation may be needed and therefore it may be a good idea to starve her from the morning before the appointment as this will provide a safer sedation.

I hope “ANIMAL NAME” recovers quickly.

Kind regards,

Name of veterinarian

Urgently: The pet needs care at a clinic within 24 hours.

Non urgently: The pet needs to visit the clinic at some point, but it's not urgent.

No: The pet do not need to go the clinic. Also click no if you say: "If it doesn't get better, go to the clinic.".

To send the journal -  click preview journal and then send.