Providing a comprehensive medical record is a requirement in delivering care on our platform, and it’s also an important element of the pet owner experience. Take a look at this blog post for a general overview of the medical records tools on Vetster, then read on below to take a deeper dive on completing your data, assessment, plan (DAP) template.
The Vetster medical records template is designed to easily capture relevant information for your appointments with a pet owner. We use the data, assessment, plan (DAP) format to share information and next steps for the pet owner, while also providing a record of the appointment itself. To use the Vetster medical record you will fill out three sections:
Data - Record the pet history, your observations, and describe the current circumstance.
Assessment - Record your diagnosis, or list of differential diagnoses.
Plan - Provide the actionable next steps for the pet owner to take. This may include prescription, triage to clinic/hospital, or at-home care and follow up.
Let’s look at each of these in more detail:
This is where you record the subjective and objective information received during your appointment.
Subjective data: Start with a thorough history. If the client has provided a note prior to their appointment, this is a good starting point. You can then take a history as you would in-clinic. Be thorough, ask questions, and listen to the pet owner’s concerns. Here are a few tips: .
Objective data: Assess the pet as thoroughly as possible via video. Walk the client through checking things you cannot see for yourself and have them report their observations to you. Video is a powerful tool when combined with pet owner insights and assessment. You should make every effort to approximate a thorough physical exam and record those findings, both normal and abnormal.
Record your differentials or diagnosis here.
If you have established a VCPR and are practicing telemedicine, do this exactly the same way as you would for a patient you are seeing in person, meeting all legal requirements for medical records documentation. If you are providing general advice, provide a description accordingly. Statements should not provide a specific diagnosis. For example, “Symptoms are consistent with…”
If you are providing teletriage, similarly stay within the guardrails of general advice and information when writing your differentials or suspected diagnosis.
Learn more about providing general advice here.
Providing a detailed action plan is an important part of the Vetster experience. This provides pet owners with appropriate next steps in the care of their animal. If you are practicing telemedicine, this section provides:
If you are providing general advice, use the plan section to summarize the information you shared with the owner. Keep your recommendations general and avoid suggesting any direct orders to the client. Instead, focus on giving the same kind of information you would find in a textbook about potential diagnostic testing, treatments, expectations, prognosis, and outcomes for the differential diagnoses recorded in the assessment section above.
If you are providing teletriage, include what urgency of care is recommended. The goal is to funnel these appointments into one of these categories:
Also include a statement about how the client always has the option to seek in-person care sooner rather than later, especially if the pet is getting worse or new symptoms arise.
Complete your medical records in a timely manner. Remote care is no different from in-clinic practice in this regard, and it is easier to produce medical records that are complete and accurate if you do it right after the appointment.
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