Clinical notes

RE: Clinical notes

Benjamin Alyoshkin — Thu, 15 Jan 2026 19:19:30 GMT

[quote userid="6765" url="~/f/non-clinical-questions/31265/clinical-notes"] find that new graduates are increasingly taught to produce voluminous notes during a consultation. This involves commenting on every single body system in detail which often becomes a time consuming tick box exercise.[/quote]

THANK YOU FOR INITIATING THIS DEBATE! I am not perfect, but add my voice to Everyone who:

- Invests time and writes notes to remind 'future self' and as a sign of professional respect to colleagues, patients, and clients, and to protect oneself if ... hits the fan;

- Writes rather than does not write. I share the views and experience of that some note writing styles are voluminous and arguably not focused. With all their imperfections and the aches of reading some volumes, I prefer them to the scarce or virtually absent note writing.

My experience of more recent graduates is more positive, I see note-writing styles that seem comprehensive, often to the point, I have seen some of my favourite notes written by younger colleagues. In comparison, some of the colleagues with gravitas do not seem to see the benefit of writing much, which is unfortunate as some of us would learn from the more experienced colleagues that way. This is also unfortunate because... and...

I guess, It's all about ongoing education at work place. I'm dreaming of the regular practice meetings and especially clinical audit meetings, that would facilitate a way of diverse note writing styles working for everyone in the team, it's all about professional conversations, feedback, attempting to optimise own style, talk again, further feedback and so perpetually, in egalitarian and open working systems. Learning, re-learning and unlearning according to Alvin Toffler is the skill to cherish (thank-you to a succinct Canadian review, published in one of vet periodicals last year).

PS I had been previously criticised by some established colleagues for my note writing, taking time during finite 15-min or 10-min appointments. They had a point, but were they open to feedback conversations or even modifying their note-writing skill? One may argue, but the thing is... not to give in

RE: Clinical notes

Neil Wheadon — Tue, 11 Nov 2025 22:58:07 GMT

OK from 35 years of experience and reading hundreds of different styles as a locum. Working on the farm 50 years ago, an old Devonian farmer called Jack taught me this 'Always think of the next man' It applies to so many things

The worst, templates. Copy and paste then fill it in. Heart, NAD, Eyes NAD, Dog has 4 legs NAD. Often for a skin condition...

The best. Sandra who worked at Companion Care was brilliant as concise and had a plan

1) History

Type as the owner talks. Let them talk, they will often give you that nugget if you let them

2) Examination

Use headers in capitals

TEETH, 108 needs attention

HEART. Put the rate in, don't write normal

Put in what is relevant, if it's normal, why mention it, unless it's something like atopy where if the axillas are normal, write that because it relates to the diagnosis and progression

3) Diagnosis

Differentials are very useful (and great CPD)

4) Plan

This is where Sandra excelled

Write what you would do next. If the faecal sample is requested, what test do you want? If the dog is lame, when do you X-Ray?

Write the drugs used, yes it takes you a few seconds, but to the next vet, it saves trawling the records and will save more time than it takes to type.

Now here's a tip, a eureka moment for me 6 months ago

In long hand type the plan, then email it to the client, they absolutely love it. 90% of your chat, anecdotes are forgotten within 5 minutes of leaving the surgery. By doing this, the next vet knows and crucially the client knows, so there is little room for confusion/complaint. Add in that link to hyperthyroidism, you know where to google, they don't and if recorded in the notes, the next vet also knows what they have looked at

Neil

RE: Clinical notes

Beats — Tue, 11 Nov 2025 22:09:43 GMT

Now we have AI and Google interpreting acronyms is only a click away:

"NOAD acronym vet" = "In veterinary medicine, NOAD is an acronym for "No Other Abnormality Detected," which is a medical shorthand indicating that a patient has been examined and no other problems were found beyond those already noted. It is often used after a comprehensive exam to conclude that the animal is otherwise healthy. "

"VS acronym vet" = "In a veterinary context, "VS" most commonly stands for Vesicular Stomatitis, a reportable disease in animals,"

"INB acronym vet" = "The acronym INB is not a standard term in veterinary medicine and likely refers to something else. While VET commonly stands for Veterinary Education and Training or Doctor of Veterinary Medicine, INB most frequently means Internet Banking in general contexts"

I rarely see notes such as:

"B; not AR"

As I was unsure what a dog which was bright, but not alert or responsive might look like, I asked Google:

"Yes, it is possible for a person to be "bright" (intelligent) but not currently alert or responsive. Intelligence and alertness are distinct functions of the brain, and they can be affected by different factors. "

I think my job as a vet is safe from being replaced by a computer just yet!

RE: Clinical notes

Neil Wheadon — Tue, 11 Nov 2025 17:36:47 GMT

[quote userid="5012" url="~/f/non-clinical-questions/31265/clinical-notes/247947#247947"]

Most of us are constantly racing the clock, so want and need to save time by using what are widely used abbreviations. Most should be self explanatory if read in context.

t'n - temperature normal, but normally I would add the value, so t'n38.2c for example. I enter this if normal to show that it has been taken. If not taken then no entry, or unable to take temp because aggressive, for example.

BAR - bright, alert responsive

VS - vital signs

NOAD - no obvious abnormality detected

INB - if no better

[/quote]

It doesn't though to be honest. Drives me absolutely nuts. It's rule 31 as a locum NEVER use these

Neil

RE: Clinical notes

Neil Wheadon — Tue, 11 Nov 2025 17:35:27 GMT

[quote userid="3169" url="~/f/non-clinical-questions/31265/clinical-notes/247942#247942"]remainder of c/e NOAD. [/quote]

NOAD ??

DMN (Drive me nuts)

TFTFIO (Takes forever to figure it out)

Neil

RE: Clinical notes

Virginia Campbell — Sun, 09 Nov 2025 21:09:02 GMT

That's a lot more useful than a potted history with

04.11.25 -------label---------

01.10.25 O brought in Miffy + Biffy. Worried Biffy is

01.10.25 ------label-------

10.07.25 -----label-------

06.04.25 rang Mrs X mob as req , no ans so tried Mr X

04.04.25 OR Biffy doing better but wants to know

02.04.25 ----label‐--------

02.04.25 t 38.7c

RE: Clinical notes

Virginia Campbell — Sun, 09 Nov 2025 20:55:25 GMT

I work for CVS so we're on Robovet, not yet been moved to Provet. I like the macros for the antiparasitics: I type in "milbd" or "milbp" or large or small dog Milbeworm and it autofills with everything required. I just delete any weight/dose brackets the dog will never be in, to keep things tidy.

Robovet (and teleos, from memory) show the dog's compressed clinical history with the top line from each entry do I make the top line a useful summary,e.g.

OE right ear

Booster lepto 4 yr 2 + Respira Bb + disp 1 x m'worm lrg

disp 60 x Epiphen 30mg 1 tab bid

Dental extract right carnassial

Spay + mammary lumpectomy

RE: Clinical notes

Virginia Campbell — Sun, 09 Nov 2025 20:14:44 GMT

I write quite a bit - to help future me and my colleagues.

I'll quite often include a note about temperament

"Best in prep room away from O, muzzle" quite often means "spolit little brat with annoying ineffectual owner, don't waste your time trying to do anything with it in the consult room"

"Muzzled as so sore but actually didn't need" means I can save time next time by just fetching the otoscope alone and also me or next vet can praise owner on arrival next time for how good dog was last time- always nice to throw them a compliment at the start.

"V competent O, drops at home no problem " or

" v well behaved but O away next week hence Osurnia" or

"No otoscopy as sore and stressed, Osurnia to avoid making headshy"

Something about future plan depending on condition with a catch point

"Rev nurse 7-10 days 2nd Osurnia then me 7-10 days after that. "

Write the prescription for the ear drops on record if next visit is nurse not vet, so they can do the Osurnia or dish out another bottle of Canaural.

"Food trial not discussed" for first offender if the left ear is pristine. If it looks a bit suspect then "brief discussion food trial, on Bakers and leftovers, treats etc, adv cut these out as too fat anyway" maybe "food trial likely difficult" doesn't take too long to write and helps out the next person a bit.

As Clive said, try to remember to write the antiparastic script and brief convo about it if you did it, to avoid some other vet 2 months hence on my day off getting landed with "Mrs X wants a Milbeworm, she was in not that long ago"

I try to get into the habit of writing something about teeth in a lot of the consults so "some tartar but gums fine, dental not req" "tartar+++ and perio dz ++ , adv dental within next X months" to avoid insurance company awkwardness so the owner can't say they weren't telt.

RE: Clinical notes

Beats — Sun, 09 Nov 2025 16:50:39 GMT

Clive, what pms would you say is most efficient, esp re parasite notes?

Do you think it is primarily the pms or the way it is configured?

Do corps tend to be better or worse than indies or is there no general rule?

Radio4 chat on productivity and efficiency in uk workplaces has really piqued my interest in this and if can move from 20% of time to 10% that would be a clear improvement irrespective of how useful we each consider notes to be compared to handwashing, active listening or any other feature of a regular consult that can be commended.

RE: Clinical notes

Clive Ansell — Sun, 09 Nov 2025 10:14:33 GMT

[quote userid="12930" url="~/f/non-clinical-questions/31265/clinical-notes/247963#247963"]What % of time should be spent on notes? [/quote]

I usual take between 1 and 2 minutes writing notes, alhough try to keep it to a mimimum. Sometimes I use templates and cut and paste to make it quicker.

[quote userid="12930" url="~/f/non-clinical-questions/31265/clinical-notes/247963#247963"]Is 5% a realistc target to be reflective of the use of those notes?[/quote]

In a 10 minute appointment, 30 seconds, not really.

in a 20 minute appointment, 1 minute, barely but possible.

But we shouldn't be time pressured, making comprehensive notes is in my mind an important and vital part of the consultation. My step daughter lawyer would say/joke spend 5 minutes on the patient then 10 minues making notes.

other thoughts:

One more recent thing that adds time to note making is having to pre authorise and specifically prescribe anti-parasitics, specifying the dosage, products, alternatives, proviso for weight gain etc etc. No longer ok to just say "OK for F&W for 12 months" takes valuable time away from examining patients and discussing with clients.

Some PMS make note making easier; separate boxes for problem, history. c/e, findings, plan etc

Other PMS make it take longer, with endless tick boxes and opt outs before you can progress to the next step - takes longer to make notes than to examine the patient. IVC's Merlin is terrible, often have to click a box before being able to move to the next stage. Pricing up a booster vaccination involves tick boxes for anal glands, dental score etc. all takes time.

RE: Clinical notes

Beats — Sun, 09 Nov 2025 03:53:54 GMT

Where i am (an average local small animal clinic), complaints are rare, thankfully.

1 x rcvs in >10 years over 8 vets (and thus 10,000s of consults) that i am aware of.

civil claims arent a particular concern to me doing the pet work i do - it would be the time taken letter-writing that would be the principle cost to be avoided rather than the potential £ liability generally.

What % of time should be spent on notes? I dont know, but would think more than 10% is eating into time that could be better spent in other ways? Is 5% a realistc target to be reflective of the use of those notes?

RE: Clinical notes

Martin Hamilton — Sun, 09 Nov 2025 02:34:41 GMT

[quote userid="3169" url="~/f/non-clinical-questions/31265/clinical-notes/247961#247961"]Ok, that rules out Canada, thanks. Looks pretty.[/quote]

On the flip side, no cascade!

RE: Clinical notes

Michael Woodhouse — Sun, 09 Nov 2025 01:35:13 GMT

[quote userid="12930" url="~/f/non-clinical-questions/31265/clinical-notes/247953#247953"]£23 for a 5 minutes appt with the vet and no notes might represent better value for money?[/quote]

Happy with 10 mins and £40? I can usually run to time or a little ahead, with notes, work booked and doing my own dispensing. I started 20 mins late this AM (down cow on my way in), saw 7 dogs, 1 cat and a calf. I finished on time. Even went out to see another cow, and was back at the surgery before 12.00. One of the dogs bled for haematology and the calf had scour samples run - not 8xPOC/boosters

[quote userid="16672" url="~/f/non-clinical-questions/31265/clinical-notes/247957#247957"]I know that here in Ontario, Canada, our provincial licensing body requires a standardised SOAP layout for records, with all body systems detailed and if not examined it has to be written down[/quote]

Ok, that rules out Canada, thanks. Looks pretty.

RE: Clinical notes

Martin Hamilton — Sat, 08 Nov 2025 13:18:08 GMT

Many of the AI scribes produce a novel as they're developed in North America, where litigation and complaints to the regulator seem more common. I know that here in Ontario, Canada, our provincial licensing body requires a standardised SOAP layout for records, with all body systems detailed and if not examined it has to be written down as such (eg. Abdomen - not palpated due to patient temperament). Differentials must be listed, and detailed treatment notes and plan written (incl. dose, frequency, next steps etc). Pain in the backside, but it is what it is.

Pretty standard for consults to be 20 mins here, if not longer, as it's been like this for several decades. Consults are around £70 on average. We don't seem to have experienced the same price inflation as the UK over the last 5 years.

The advantage of AI scribes is that you can find tune the level of detail they output, and even provide them with a template or framework to work within. As for errors, you always have to double check them, but so far I've found them to be a huge time saver.

RE: Clinical notes

Clive Ansell — Sat, 08 Nov 2025 09:46:25 GMT

[quote userid="12930" url="~/f/non-clinical-questions/31265/clinical-notes/247953#247953"]

Is there a cheaper appt charge without the notes option?

£23 for a 5 minutes appt with the vet and no notes might represent better value for money?

[/quote]

Why would you want too?

Contemporaneous notes are vital and will help support you in the event of a complaint or a claim.

I used to do a fair amount of court work on behalf of the RSPCA and occasionally the police, and have been crossed questioned in court many times by solicitors and barristers. A lot of weight is given to clinical notes, in particular to what is not written more so than what is. They will often question the accuracy of a statement, based on clinical notes, where it is written many months after the event. Maybe it is this background that makes me more cautious or pedantic. Again, I can write short concise complete notes within the standard consultation timeframe.

RE: Clinical notes

Beats — Fri, 07 Nov 2025 20:31:38 GMT

[quote userid="5012" url="~/f/non-clinical-questions/31265/clinical-notes/247952#247952"]Also I think for nearly £70 a pop[/quote]

Is there a cheaper appt charge without the notes option?

£23 for a 5 minutes appt with the vet and no notes might represent better value for money?

I entirely agree that working as a locum is very different w.r.t. note-making, but in a normal setting where I am writing notes these are purely an aide memoir for myself to jog my memory. There may be the occasional client where I write defensive-style notes, but these are infrequent and tailored to the uniqueness of the interaction I am having (or knowledge of a previous interaction) and are written for the benefit of a third-party; I would think it a total waste of time to do this for every appt however.

Think of a risk-based approach to note-taking that goes beyond being useful to you. Chances that you might have to spend time letter writing at a later date = worth spending more time writing stuff now to save time later. Otherwise don't waste time on a remote chance that may be of benefit (more benefit than using your time more profitably in the here and now) in some hypothetical, but highly improbable, scenario.

RE: Clinical notes

Clive Ansell — Fri, 07 Nov 2025 18:03:55 GMT

[quote userid="3169" url="~/f/non-clinical-questions/31265/clinical-notes/247942#247942"]

Short?! From me you'd get:

Otitis R ear. Disc atopy & cleaning once recovered

RV 7d, 2nd Osurnia

[/quote]

We work in different environments.

You are practice owner and can do as you like; you likely know the client and will likely see them next time.

I am a locum, often not familiar with the case or the client. I don't who will see the case next time around and want to leave good concise notes for them.

Also I think for nearly £70 a pop, clients deserve a full history taking and clinical examination with thorough clinical notes made. They can short and concise, don't need to write out Lord of the Rings every time.

RE: Clinical notes

Clive Ansell — Fri, 07 Nov 2025 17:56:54 GMT

[quote userid="10320" url="~/f/non-clinical-questions/31265/clinical-notes/247949#247949"]I think yes, a fear of litigation/ complaint plays a role; not only of RCVS complaints, I think just the lower level "mrs y says you didn't even look in the dog's ears" level of whinging, but I wonder how much this is influenced by practice management response to complaints.[/quote]

I think that is very true.

I've had many low levels whingers' in the past; thinks like vet didn't look in his ears, vet didn't take his temperature, didn't look in his mouth, didn't examine properly. It's possible to record observations with very concise notes, and cover ones arse at the same time.

If you enter in to the notes "ear canal sore, TM intact, no FB seen" or "T'n382c" your butt is covered if someone complains you didn't do it.

RE: Clinical notes

Lucy Fleming — Fri, 07 Nov 2025 16:07:04 GMT

I think yes, a fear of litigation/ complaint plays a role; not only of RCVS complaints, I think just the lower level "mrs y says you didn't even look in the dog's ears" level of whinging, but I wonder how much this is influenced by practice management response to complaints.

I do also think that confidence in diagnosis/ plan is part of it as well. I know that if I see a case where I genuinely have NO IDEA what might be going on, I tend to end up writing a novel, possibly fear of leaving out something that later turns out to be relevant (but I didn't realise at the time, because I had NO IDEA what might be going on...) Or perhaps more in the misguided hope that a colleague will spot the hidden gem of relevant information, use it to reach a diagnosis and take the whole case off my hands never to bother me again.

If you have a much clearer idea of likely diagnosis and a reasonable plan, then it's easier to be succinct, but that can take time to develop. Damned pattern recognition...

RE: Clinical notes

Dinu Catilina — Fri, 07 Nov 2025 11:55:23 GMT

Yes, too much. And with the AI transcripted notes it's a novel now that takes three times longer to read. So now the AI will also offer an AI service to summarise the AI inflated notes. F**k me...

My question though is if the AI misunderstands you and then the other AI misinterprets the misunderstood notes who's fault is it? Why are we, as a profession, hell bent to make our lives more difficult? We keep hearing about litigation but I don't know anyone who has been removed from the register because notes were not exhaustive enough. Yes, contemporaneous helps but other than that it was the action not the quality of the notes that counted.

It looks like making the appointments longer does not increase the quality of care but the admin work done around the patient.

RE: Clinical notes

Clive Ansell — Fri, 07 Nov 2025 10:38:54 GMT

Most of us are constantly racing the clock, so want and need to save time by using what are widely used abbreviations. Most should be self explanatory if read in context.

BAR - bright, alert responsive

VS - vital signs

NOAD - no obvious abnormality detected

INB - if no better

RE: Clinical notes

Chris Geddes — Fri, 07 Nov 2025 09:49:56 GMT

What does t'n mean? I could guess temperature normal but not sure why you'd take it for this case.

And VS? The veterinary surgeon is within normal limits?

What about NOAD? I presumed no abnormalities detected but then there is NAD above.

INB? Something about if no improvement?

This nicely illustrates the problem with using abbreviations/initialisms and presuming that everybody understands. 20 years qualified and half of those lost on me.

RE: Clinical notes

gdbvet — Thu, 06 Nov 2025 23:18:08 GMT

Adopt AI asap to write notes from a verbal description.As a lawyer friend of mine commented.”I thought the whole point in going to the vet was to make my dog better,not the volume of notes.”

RE: Clinical notes

Rob Loxley — Thu, 06 Nov 2025 23:04:59 GMT

[quote userid="6765" url="~/f/non-clinical-questions/31265/clinical-notes"] in future is becoming outdated[/quote]

Surely AI will be transcribing all our consultations soon!

RE: Clinical notes

Michael Woodhouse — Thu, 06 Nov 2025 23:04:18 GMT

[quote userid="5012" url="~/f/non-clinical-questions/31265/clinical-notes/247935#247935"]

I keep notes very short, often short sentences or bullet points, and usual separate in to sections; for example.

Issue:

sore ear over the last week, otherwise well. no known Hx of ear or skin disease. O' has used OTC cleaner which has not helped. up to date with ecto-parasite control

c/e:

BAR and VS all wnl. t'n.

R OE +++. canal and pinna inflammed and erythematous, moderate amnt odorous debris in canal. NO FB seen. intact TM

L ear NAD. skin NAD

remainder of c/e NOAD.

findings/diagnois: R OE. +/- related to allergy/atopy

plan: adv ear cleaner daily along with medicated ear drops, but INB may need to consider euga/flush and clean/swabs for cytology and/or C&S

[/quote]

Short?! From me you'd get:

Otitis R ear. Disc atopy & cleaning once recovered

RV 7d, 2nd Osurnia

I hate it when I spend 2 mins trying to figure out what is wrong with the animal. Find I either get a long essay or nothing as someone is planning on going back and writing the essay later and it's not happened.