Veterinary SOAP Notes | Templates and Examples

Vet SOAP notes are a structured method of documenting patient information in veterinary medicine, designed to ensure thorough and organized medical records. SOAP stands for:

• Subjective: This section includes the veterinarian’s observations and the pet owner’s descriptions of the animal’s condition, such as behavior changes, appetite, and activity level.
• Objective: This part records measurable data from the physical exam and diagnostic tests, including temperature, heart rate, lab results, and imaging findings.
• Assessment: Here, the veterinarian synthesizes the subjective and objective information to form a diagnosis or list of potential diagnoses.
• Plan: This section outlines the recommended treatments, follow-up care, and any additional diagnostics needed.

The SOAP format helps ensure that all relevant aspects of the patient’s health are considered, leading to comprehensive and effective treatment plans.

Using Vet SOAP note templates offers numerous benefits for veterinary professionals, including:

• Standardization: Ensures consistent documentation across different cases and professionals.
• Improved Communication: Enhances communication among veterinary staff and other healthcare providers.
• Efficiency: Streamlines the documentation process, saving time and allowing veterinarians to focus more on patient care.
• Comprehensive Records: Ensures thorough and accurate medical records, covering all aspects of patient care.
• Enhanced Care Quality: Leads to better patient outcomes and client satisfaction by ensuring no critical information is omitted.

How TextExpander Can Help

Using TextExpander can significantly enhance veterinarian efficiency by optimizing the use of templates and the tool itself. Here are some key ways TextExpander helps:

• Quick Access to Templates: TextExpander allows vets to create and access templates for common tasks quickly, reducing the time spent on documentation. This includes SOAP notes, client education materials, and treatment plans.
• Snippet Organization: Organizing snippets into groups based on specific needs (e.g., different types of medical notes) helps in maintaining a structured and efficient workflow.
• Customization and Adaptability: TextExpander allows for easy customization of snippets to fit specific needs, making it adaptable to various veterinary practices and workflows.

By taking advantage of these features, veterinarians can enhance their documentation processes, reduce administrative burdens, and focus more on patient care.

Veterinary SOAP Note Example 1: Bella

Subjective

Patient Information:
– Name: Bella
– Species/Breed: Canine/Labrador Retriever
– Age: 6 years
– Sex: Female (spayed)
– Color/Markings: Yellow

Chief Complaint:
– Bella has been lethargic and refusing to eat for the past two days.

History:
– Previous history of hypothyroidism, currently on Levothyroxine.
Up-to-date on vaccinations.

Objective

Physical Examination Findings:
– Temperature: 102.1°F
– Heart Rate: 90 bpm
– Respiratory Rate: 25 breaths/min
– Weight: 65 lbs
– Mucous Membranes: Pink, slightly dry
– Capillary Refill Time: <2 seconds
– Body Condition Score: 5/9

Diagnostic Test Results:
– Blood work: Elevated liver enzymes
– Urinalysis: Normal

Assessment

Differential Diagnoses:
– Hepatitis
– Pancreatitis
– Gastroenteritis

Definitive Diagnosis:
– Suspected acute hepatitis

Plan

Treatment Plan:
– Prescribed Denamarin for liver support
– Recommended bland diet (boiled chicken and rice)
– Administered subcutaneous fluids for hydration

Follow-Up:
– Recheck liver enzymes in one week
– Owner to monitor appetite and energy levels, report any vomiting or diarrhea

Veterinary SOAP Note Example 2: Whiskers

Subjective

Patient Information:
– Name: Whiskers
– Species/Breed: Feline/Domestic Shorthair
– Age: 3 years
– Sex: Male (neutered)
– Color/Markings: Black and white

Chief Complaint:
– Whiskers has been sneezing frequently and has nasal discharge.

History:
– Indoor cat with no previous health issues.
– No recent changes in environment or diet.

Objective

Physical Examination Findings:
– Temperature: 101.5°F
– Heart Rate: 150 bpm
– Respiratory Rate: 30 breaths/min
– Weight: 10 lbs
– Mucous Membranes: Pink
– Capillary Refill Time: <2 seconds
– Body Condition Score: 5/9

Diagnostic Test Results:
– Nasal swab: Positive for feline herpesvirus

Assessment

Differential Diagnoses:
– Upper respiratory infection (URI)
– Allergies
– Nasal polyps

Definitive Diagnosis:
– Feline herpesvirus infection

Plan

Treatment Plan:
– Prescribed L-lysine supplement to boost immune response
– Recommended humidifier use to alleviate congestion
– Advised saline nasal drops as needed

Follow-Up:
– Monitor for improvement over the next week
– Return for re-evaluation if symptoms persist or worsen

Veterinary SOAP Note Example 3: Max

Subjective

Patient Information:
– Name: Max
– Species/Breed: Canine/German Shepherd
– Age: 8 years
– Sex: Male (neutered)
– Color/Markings: Black and tan

Chief Complaint:
– Max has been limping on his right hind leg for the past three days.

History:
– History of hip dysplasia, managed with joint supplements.
– Regularly exercised with daily walks.

Objective

Physical Examination Findings:
– Temperature: 101.8°F
– Heart Rate: 80 bpm
– Respiratory Rate: 22 breaths/min
– Weight: 85 lbs
– Mucous Membranes: Pink
– Capillary Refill Time: <2 seconds
– Body Condition Score: 6/9
– Lameness: Noted in right hind leg, pain on palpation of the hip joint

Diagnostic Test Results:
– X-rays: Evidence of osteoarthritis in the right hip

Assessment

Differential Diagnoses:
– Osteoarthritis flare-up
– Ligament injury
– Muscle strain
– Definitive Diagnosis:
– Osteoarthritis flare-up

Plan

Treatment Plan:
– Prescribed Carprofen for pain and inflammation
– Advised rest and limited activity for one week
– Continue joint supplements (Glucosamine and Chondroitin)

Follow-Up:
– Re-evaluate in two weeks
– Discuss potential for physical therapy if no improvement