Veterinarian Visit Notes
A veterinary visit record — clinic, patient signalment (species/breed/sex/age/weight) and owner, reason for visit, vitals, SOAP note, vaccines and medications given/prescribed, and plan/recheck.
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Maplewood Animal Hospital
VETERINARY VISIT NOTES
Veterinarian: Dr. Priya Shah, DVM Date: June 19, 2026
Owner: Alex Morgan
Patient: Biscuit Canine · Labrador Retriever · MN · 6 yr
Weight: 31.2 kg (68.8 lb)
Reason: Annual wellness exam + vaccines; owner notes mild left-ear scratching.
VITALS
T 101.5°F · HR 90 · RR 22 · BCS 6/9 · MM pink, CRT <2s.
S — SUBJECTIVE (history)
Eating/drinking normally, BAR at home. Occasional left-ear scratching x1 week. On monthly flea/tick + heartworm prevention. No vomiting/diarrhea, no coughing.
O — OBJECTIVE (exam)
BAR, hydrated. Eyes/oral clear; mild grade 1 dental tartar. Heart/lungs NSF on auscultation. Abdomen soft, non-painful. Left ear: mild erythema + light brown debris; right ear clean. MSK: normal gait. Skin/coat good.
A — ASSESSMENT
1) Healthy adult dog, wellness exam WNL. 2) Mild left otitis externa (suspect early yeast). 3) Grade 1 dental tartar.
P — PLAN / RECHECK
Ear cytology -> medicate per results; clean + topical otic BID x7d. Discussed dental cleaning within 6 months. Recheck ear in 2 weeks if not resolved. Continue prevention.
VACCINES / MEDICATIONS
Rabies (3-yr) RFP lot #A1234 exp 2028-04, right hind. DHPP booster, left hind. Dispensed: otic suspension 15 mL, apply BID x7d. Heartworm test negative.
Veterinarian signature: ____________________________ Date: ______________
Dr. Priya Shah, DVM
About this template
A veterinary visit note is the SOAP record for an animal patient, and the parts that differ most from a human chart are at the top: the **signalment** (species, breed, sex/neuter status, age) and **weight**, which drive everything from drug dosing to what is normal, plus the **owner** as the historian. Vitals for animals include temperature, heart and respiratory rate, **body condition score (BCS)**, and mucous-membrane/CRT. From there it is standard SOAP: **Subjective** is the owner's history (appetite, behavior, the presenting concern, prevention status); **Objective** is the physical exam, system by system; **Assessment** is the problem list; and **Plan** covers diagnostics, treatment, client communication, and the recheck. Two sections carry legal weight in veterinary practice. **Vaccines and medications** should record the product, lot/serial and expiration, and site for vaccines (rabies in particular has certificate and reporting requirements in many states), and any dispensed or prescribed drugs — with controlled substances following DEA/state rules. And everything depends on a valid **VCPR** (Veterinarian-Client-Patient Relationship), which is required to diagnose, treat, or prescribe. Keep records per your state practice act's content and retention requirements, write them contemporaneously, and remember the note documents care provided under professional judgment — it is not a substitute for examining the patient.
When to use it
- Documenting a wellness or problem-focused veterinary visit.
- Recording signalment, vitals, and a SOAP exam.
- Logging vaccines (with lot/expiration/site) and medications.
- Setting a treatment plan and recheck.
What to include
- Clinic, veterinarian, owner, and patient signalment + weight.
- Reason for visit and vitals (T/P/R, BCS).
- SOAP: history, exam findings, assessment, plan.
- Vaccines (product/lot/expiration/site) and medications.
- Recheck and veterinarian signature.