Ortega, Louise Alysson C.

DVM5

Veterinary Clinical Orientation 1 – Clerkship

Laboratory Exercise 1
CLINICAL RECORDS and RECORD KEEPING

Desired Learning Outcomes

At the end of the class, the students can:
1. Name the different clinical records or forms used in veterinary hospitals and clinics.
2. Properly fill up the information needed in the record and be familiar with how to gather
information from clients regarding their pet patient.
3. Discuss the common and the differences in clinical records from veterinary institutions
they will encounter.

Introduction
Veterinary practice in companion animals has grown exponentially through the years.
This is not only manifested in the number of veterinary practices being put up but also in the
number of products, equipment, and technologies that are coming out for the betterment of the
companion animal practice.

As in any institution, records will play a vital role in organizing the flow of the practice
or work done. Clinical records not only will make the procedures to be done with these
companion animals more organized, but they will also serve as a tool for the practitioner to
conduct the proper examination and related procedures for the pet patient in a systematized
way.

Another importance of clinical records is that this record will be the hard document on
what has been done, be done, and what was given and not to the companion animal when the
need arises that an inquiry by another veterinarian who may be handling the patient in the
absence of the other one who initially handled the patient can rely on.

Clinical records serve important roles and purposes for any clinician/practicing
veterinarian for them to be able to perform their duty properly to their companion animal
patients.

Materials
Sample Medical Record
Other Clinical Records: Laboratory request forms, Dermatology records, Consent forms
Pen
Video
Learning Activities
1. Below are sample clinical records used by veterinary teaching hospitals (used by DLSAU
VTH). Identify the following clinical records and briefly discuss the uses of each
record/form in companion animal practice.

a. Medical Record
Records are kept so you can keep track of the patient's
medical situation. The DVM will record any abnormalities
found during the assessment of a patient upon admission to
the hospital, as well as any suggested diagnostic
procedures or treatments. The doctor and the pet owner can
both benefit from knowing what has previously happened to
their pet because of these clinical data. To preserve an
accurate record of how a patient is responding to
medication and any notes regarding these patients' health,
veterinary medical record keeping is crucial. A veterinarian
would be unable to recall every patient they visit, the
prescriptions they administered, and the surgeries they oversaw throughout the
duration of the patient's life without these clinical records. In addition to acquiring
important details about your patients, medical records can defend you from
erroneous accusations of negligence. In the event of a malpractice claim or license
complaint, the veterinarian faces the danger of not being able to demonstrate
acceptable care without the correct documentation.

b. Dermatology Record
A dermatology record is a clinical record that is vital in
evaluating skin diseases in animals. Taking a thorough patient
history is fundamental in assessing patients with skin disease.
The clinical signs, age of onset, duration, location, and extent
of pruritus, treatments already used, and many more factors
are often valuable clues for diagnosis. Obtaining all the
necessary information is a time-consuming task that may
seem impossible to accomplish in a brief office visit but is vital
to confirm a diagnosis. Using a dermatology history form is
greatly helpful in this regard.

c. Consent Form
The main purpose of the informed consent process
is to protect both the doctor and the patient. When
clients agree to a treatment, they must sign
paperwork indicating they understand the risks
and agreeing doctors can take specific life-saving
measures if needed. Informed consent creates
trust between doctors and clients by ensuring good
understanding. It also reduces the risk for both.
2. There are cases you will encounter in clinical practice where laboratory tests may be
required to assess the case. For example, if you are handling a case that is said to be
showing signs of itchiness and hair loss, give at least two diagnostic tests you may
request to be checked to diagnose your case. Discuss briefly also why you would request
these tests on your patient.

• Skin Cytology – a powerful tool for the evaluation of skin lesions in small animal
patients. In many cases, cytology can provide a definitive diagnosis for cutaneous
masses. In this case, there is a presentation of hair loss during physical
examination, it can be a mange mite infection because the patient also presented
pruritus. The infection can be diagnosed using cytology.
• Skin Scraping – a typically performed test to aid in diagnosing certain skin
inflammations, fungal infections, and skin cancer, along with being an effective
way of determining the presence of mites. It can reveal the presence of abnormal
cells in the superficial layers of the skin. Determining the underlying cause leads
to appropriate treatment.

3. In relation to question # 2, look for a picture of a pet with a skin problem on the internet
(or if you happen to have an old file) from a veterinary clinic or hospital and discuss the
possible disease condition of the pet.

A possible disease condition

of this pet is Sarcoptic Mange
or Canine Scabies.
Symptoms usually include
hair loss and severe itching
especially on the elbows,
ears, armpits, hocks, chest,
and ventral abdomen (belly).
As the infection worsens, it
can spread over the entire
body.

Small red pustules often

develop along with yellow crusts on the skin usually indicating a bacterial skin infection
secondary to the mite infection. If the infection goes untreated or is mistakenly treated
as an allergy, the skin may darken due to constant irritation, and the surrounding lymph
nodes may become enlarged.

Trying to make a diagnosis of canine scabies can be very frustrating. The standard
method is to perform a skin scraping and then identify the mite under the microscope.
Unfortunately, on average, only 20% of infected dogs will show mites on any given
scraping. Most cases are diagnosed based on history and response to treatment for
scabies.
4. Identify the clinical record/form below and when is this record/form needed in
companion animal practice?
Euthanasia Consent Form

Euthanasia is a method of killing that

minimizes pain, distress, and anxiety
experienced by the animal before the loss of
consciousness.

It is needed in companion animal practice

when an owner and veterinarian decide that
a pet is suffering or unlikely to make a
recovery. It is a way to end a pet’s pain by
giving it a humane death.

5. If you happen to have a pet with you, create a Medical Record for him/her by giving the
information needed in a medical record like the one below from the DLSAU – Veterinary
Teaching Hospital. Put your pet’s info after this picture (or should you wish to write on
this form, it’s your call).

OWNER’S NAME: Ortega, Louise Alysson C.

PET’S NAME: Jennifer
ADDRESS: Quezon City
TEL. NO.: 0908 383 2509
SPECIES: Feline
BREED: Maine Coon
AGE: 6 months
SEX: Female
MARKINGS: Brindle
 VACCINATION UPDATES
Vaccine When (Year) Expiration
4-in-1 May 17, 2022 May 17, 2023
ARV May 31, 2022 May 31, 2023

PRESENTING COMPLAINT/REQUESTS: Wellness check-up

MEDICAL HISTORY: Exceptionally healthy. Diet is Royal Canin’s Maine Coon Kitten Dry
Cat Food. Observed presence of fleas last month but have already given Frontline Plus.

PHYSICAL EXAMINATION:
TEMP: 38.6C RR: 21/min HR: 130bpm WT: 4.8kg

ABNORMAL FINDINGS
General Appearance: Normal Lymph nodes: Normal
Skin: Normal Nervous/Reflexes: Normal
Mucous Membrane: Normal Gastro-intestinal: Normal
Eyes: Normal Musculoskeletal: Normal
Nose: Normal Respiratory: Normal

LABORATORY EXAMINATION
X-RAY Findings: None SS: None
DFS: None VS: None
FE: None Direct Smear: None

TENTATIVE DIAGNOSIS: Healthy

CONFIRMATORY DIAGNOSIS: Healthy

TREATMENT PRESCRIPTION
Continue a healthy diet and give Nutri-plus Gel
supplements. Give 1tsp once a day as a supplement

References:
DLSAU Veterinary Hospital Medical Record Forms
https://televet.com/blog/veterinary-record-keeping
https://www.msdvetmanual.com/euthanasia/euthanasia-of-animals
https://vcahospitals.com/know-your-pet/mange-sarcoptic-in-dogs