Veterinary Progress Note

Template structure

This is the structure Notat follows when it writes the note from the visit — you never fill it in by hand.

Veterinarian Note Template

Patient Identification:
[Animal name], [species/breed], [age], [sex], presenting for [chief complaint or reason for visit]

History of Present Illness:
[Description of presenting complaint, onset, duration, progression, associated symptoms, previous treatments or interventions]

Past Medical History:
(hyphenated list)
- [Previous illnesses, surgeries, chronic conditions, vaccinations]

Medications:
(hyphenated list)
- [Medication name, dose, route, frequency]

Allergies:
(hyphenated list)
- [Known drug or food allergies]

Diet and Environment:
(hyphenated list)
- [Type of diet, feeding schedule]
- [Living environment: indoor/outdoor, other animals, exposures]

Physical Examination:
(hyphenated list)
- [Weight: # kg, Temperature: #°C, Heart rate: # bpm, Respiratory rate: # bpm]
- [General appearance: findings]
- [Skin/Coat: findings]
- [Eyes/Ears/Nose/Throat: findings]
- [Cardiovascular: findings]
- [Respiratory: findings]
- [Abdominal: findings]
- [Musculoskeletal: findings]
- [Neurological: findings]
- [Other relevant systems: findings]

Diagnostics:
(hyphenated list)
- [Laboratory results, imaging findings, other diagnostic tests with units]

Assessment:
(hyphenated list)
- [Primary diagnosis or problem list]
- [Differential diagnosis if applicable]

Plan:
(hyphenated list)
- [Further diagnostics planned or ordered]
- [Treatment plan: medications, procedures, supportive care]
- [Client education and counselling]
- [Referrals if needed]
- [Follow up plan]
- [Emergency/return precautions]