From unacceptable to exceptional: DAP examples that set the standard

Medical records are the foundation of veterinary practice. They capture the story of the patient, the veterinarian’s reasoning, and the plan for moving forward. High-quality records protect veterinarians, support continuity of care, and build client trust.

On Vetster, medical records carry additional weight. They are not just your professional notes, they are also a client communication tool and part of what pet owners value in their Vetster experience. Unlike in a brick-and-mortar clinic where records mostly stay within the hospital, Vetster clients depend on your notes as their written take-home instructions, and in many cases bring them to an in-person veterinarian for follow-up. That means the record itself must be clear, complete, and client-friendly to ensure continuity of care across both virtual and in-person settings.

This article reviews the fundamentals of medical record-keeping with specific application to practicing on Vetster. We will walk through the purpose of medical records, introduce Vetster’s DAP format and how to use it effectively, define the platform’s required standards, and evaluate real examples ranging from unacceptable to exceptional. By the end, you’ll have a clear picture of what Vetster requires in every medical record and why.

The primary purposes of medical records are twofold everywhere in veterinary medicine, but they take on added importance in virtual care:

• Continuity of care: Records allow any veterinarian reviewing the file to understand the patient’s history, diagnostic considerations, and next steps, whether weeks later, in a different clinic, or on a new platform. On Vetster, this continuity is especially important because pets often transition directly from a virtual appointment to an in-person exam. Your record is frequently the only hand-off document the client can bring with them. Clear, client-friendly notes build trust, support consistent care across providers, and give pet owners confidence that their pet’s needs are understood.
• Legal defense: Veterinary practice acts consistently define medical records as the official documentation of care. In the event of a board complaint or malpractice allegation, your record is the primary evidence of what was said, done, and recommended. A thorough record is your strongest defense; a sparse or vague record can work against you even if you delivered appropriate care.

Regulatory boards echo this expectation by requiring specific elements to be documented for each patient encounter, including signalment, presenting complaint, history, examination findings, assessment, treatment plan, and client communication. Vetster’s requirements mirror these expectations while adding emphasis on clarity for clients and accessibility for other veterinarians.

The DAP format offers a simple but powerful framework for organizing medical records:

• Data (D): Objective and subjective information gathered from the client and examination. This includes signalment, history, presenting complaint, and video exam findings. This is equivalent to both the “S” and “O” sections of a SOAP record format.
• Assessment (A): The veterinarian’s clinical reasoning, including problem lists, differential diagnoses, and interpretation of the data.
• Plan (P): Recommended diagnostics, treatments, follow-up, and client education, with documentation of the client’s understanding and agreement.

Most veterinarians know the basics of what belongs in a DAP, but on Vetster, simply entering the minimum isn’t enough. The difference between unacceptable and exceptional is clarity, completeness, and whether another professional, or even the client can understand exactly what happened and why.

On Vetster, we set standards for medical records to support both quality of care and client confidence. At a baseline, every record must:

1. Reflect a thorough history, including presenting complaint.
2. Demonstrate that the animal was examined during the appointment and note relevant findings.
3. Outline clear next steps in client-friendly language, since this record doubles as the client’s take-home instructions.
4. Be completed within 24 hours of the appointment. This is critical in virtual care, where delays can leave a pet parent without guidance and in some cases result in them arriving at an in-person clinic with no record in hand.

These requirements apply to every Vetster appointment, including telemedicine, teletriage, and general advice consultations, so that all interactions provide the same value and level of professionalism and accountability. These baseline standards represent the floor, not the ceiling. Your records are ultimately your professional property, and more detail always works in your favor.

Comprehensive records reflect the quality of your practice, strengthen client trust, and offer you the best protection should questions ever arise. Learn more here:

• Vetster standards for virtual care appointments
• Vetster’s Virtual Care Master Class
• Vetster’s DAP template
• Completing medical records on Vetster

These standards are non-negotiable on Vetster. Records that are incomplete or late create real consequences not just for patients and clients, but also for Vetster operations. Every time our team has to track down missing records, it consumes staff resources and slows down workflows. In some cases, when clients are left without the information they paid for, Vetster must absorb the cost of refunded appointments.

A completed, high-quality record within 24 hours also directly contributes to your visibility on the platform, which leads to more bookings. Completing your record accurately and on time benefits your practice and is part of your professional responsibility on Vetster. This ensures a smooth, safe experience for everyone involved.

Below, we share simulated examples that illustrate how to take a record from unacceptable to exceptional. **These examples are intended solely to demonstrate documentation practices on Vetster. They are not meant to represent optimal case management or comprehensive medical decision-making, which will always depend on the individual patient and clinical context.

Case 1: Vomiting dog

Here’s an example of an unacceptable DAP:

D: Vomiting since yesterday

A: Suspect dietary indiscretion

P: NPO x 12 hrs, bland diet, recheck if not improving

Here’s an example of how this DAP could become exceptional:

Why it’s exceptional: Overall thoroughness including noting normal exam findings, differential list, red flags, clear next steps, and sharing client education make this record exceptional.

Case 2: Itchy cat

Here’s an example of an unacceptable DAP:

D: 6yo FS DSH cat, pruritus 2 months. Owner reports using flea control, no other pets. PE: limited, mild alopecia on neck visible on camera

A: Allergic dermatitis.

P: Trial antihistamine, monitor.

Here’s an example of how this DAP could become exceptional:

Why it’s exceptional: This record reflects a thorough history and video exam, focuses on client education, and provides clear next steps.

Case 3: Chronic arthritis management in senior dog

Here’s an example of an unacceptable DAP:

D: Refill meds

A: Osteoarthritis

P: Rimadyl

Here’s an example of how this DAP could become exceptional:

Why it’s exceptional: This record not only shows a thorough history and video exam, it presents clear next steps in client-friendly language that include links to reliable sources for client education. This adds value and also has the potential to improve compliance and care.

Exceptional records do more than check boxes:

• Demonstrate thoughtful clinical reasoning.
• Improve client compliance and understanding.
• Reduce liability by documenting warnings and education.
• Support continuity of care if another vet reviews the record.

At Vetster, strong records are a marker of professional excellence. They help ensure telehealth meets the same high standards as in-person care and help protect you, your patients, and your clients.

Key takeaway: When in doubt, ask yourself: Could another vet understand my thinking and next steps by reading this note alone? If the answer is yes, you’re not just meeting the standard. You’re setting it.

When you set the standard for your records, you’re not just protecting yourself — you're building a more successful, trustworthy, and profitable virtual practice.

Learn more about how Vetster helps you grow your practice here.