Describe three items that will be included in veterinary practice documentation for individual animals

Answer 1

Any three of the following:
Owner (client) identification: name, address, telephone numbers for home and office at a minimum; additional information may include names, addresses, and tele-phone numbers for alternate or co-owners of the animal
Animal (patient) identification: name, identification number if applicable (i.e., tattoo or identification chip), species, breed, date of birth, sex, color, and/or markings
Vaccination history of the patient
Chief complaint: observations reported by the client
Medical history
Physical examination, including the current weight of the animal
Problem list
Diagnostic reports (e.g., laboratory, diagnostic imaging, etc.)
Patient-identifiable source data, including photographs, video recordings, audio recordings, diagnostic films, and electrocardiogram tracings
Consultation reports, including those of telephone consultations
Prognosis
Progress notes recording medical and surgical events should be made in chronological order; communications with the client should be documented, including waiver or deferral of recommended care.
Surgical and dental records, including the consent form signed by the client
Written discharge summary and instructions
Necropsy reports, when applicable. (A necropsy is a postmortem examination to determine the cause of death or the character and extent of changes produced by the disease.)
Financial records