Reception of patient and recording in patient file

Receiving sets the tone for the entire visit. You create calm for the animal and owner, gather the information the veterinarian needs, and document everything correctly in the medical record.

Anamnesis is the information you gather from the owner about the animal and its problem. Ask open questions and listen, but make sure to get concrete information.

• 01What is the reason for the visit, and when did it start?
• 02Changes in appetite, water intake, bowel movements and urination.
• 03Behaviour, activity and general condition.
• 04Previous disease, treatment, vaccination and medicine.
• 05Feed environment and whether other animals in the household are affected.

While you talk to the owner, you observe the animal: how it moves, breathing, mucous membranes, coat/skin and general condition. These observations are noted objectively and help the veterinarian move forward with the examination.

The journal documents the animal's health and treatment, ensures continuity and allows a colleague to take over without losing important information.

• 01Note date, animal, owner and contact information.
• 02Describe case history and observations separately from the veterinarian's assessment.
• 03Document treatment given, medicine and dosage as prescribed.
• 04Note agreements on follow-up and inspection.

A good record means a colleague can take over the patient without losing track — and it is crucial if treatment is later to be assessed.