https://www.vetnurse.co.uk/f/nonclinical-discussions/11499/outline-of-consultaion-notes We are currently trying to get our vets to use the same layout / template for their consultaion or operation notes. At the minute our vets either write very minimal or a 1000 word essay! The nurses here are wanting a simple but instructive structureen-USTelligent Community 10https://www.vetnurse.co.uk/thread/103120?ContentTypeID=1Wed, 01 Dec 2010 09:10:52 GMT1a0763ec-3885-442c-853e-6cef656dfec5:4e394338-c624-4212-b39d-254e15c028e0Nick Shackleton <p>Many vets use the S.O.A.P&nbsp;</p> <p> <ul> <li><b>Subjective:</b>&nbsp;The patients current condition ie presenting problem in the words of the owner.</li> </ul> <ul> <li><b>Objective:</b>&nbsp;Vital signs, findings from examination, and measurements such as TPR, weight etc..</li> </ul> <ul> <li><b>Assessment: </b>A quick summary of the patients main symptoms as well as a diagnosis as well as any differential diagnosis.</li> </ul> <ul> <li><b>Plan:</b>&nbsp;What is the plan for the case inc any medications, tests, such as rads, lab test etc. Or requests for referral etc...</li> </ul> </p><div style="clear:both;"></div>https://www.vetnurse.co.uk/thread/103118?ContentTypeID=1Wed, 01 Dec 2010 08:42:30 GMT1a0763ec-3885-442c-853e-6cef656dfec5:fcb3cd77-9e41-4e0a-9d2b-d59ff2bfc51bjenny munro<p>Hi, </p> <p>Yes that does help, thanks! </p><div style="clear:both;"></div>https://www.vetnurse.co.uk/thread/103084?ContentTypeID=1Tue, 30 Nov 2010 17:05:34 GMT1a0763ec-3885-442c-853e-6cef656dfec5:80c4a0d2-6680-4237-b5f7-63cb29ac6a65Lorena Williamson<p>Hiya,</p> <p>not sure if this helps but on our system, our vets follow this template:</p> <p>History: basically why they are here, have they been before</p> <p>Examination: what the vets has found during consult</p> <p>Diagnosis: what the vet thinks it might be</p> <p>Plan: what they want to do next. tests/surgery/follow up appointments.</p> <p>is that helpful at all?</p> <p>&nbsp;</p><div style="clear:both;"></div>