Abstract
Veterinary medical records serve several purposes. Medical records are a document of information that provides what has occurred to the patient while they have been in the care of the veterinary health care team in the hospital. Because a medical record is frequently referenced, an accurate and clearly written record is of the utmost importance. A standardized medical record organization is important for many reasons. An organized medical record is most commonly formatted in a chronological order. There are two common formats used for the documentation of medical records: the conventional method and the problem-oriented medical record. The complete medical record should include nine components: client information; patient information; presenting complaint; history; physical examination; problem lists; progress notes; communication log; and comments. In addition to details about patient data, future treatment and diagnostic plans, and client education, a medical record should include clinician order sheets and treatment/flow sheets.
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