The fast pace of emergency medicine requires the veterinary team to keep a particularly vigilant watch over medical records. Otherwise, important details could be missed.
What to record during an emergency:
Physical examination findings; dosages and time of administration of medications; copies of diagnostic data or procedures; all radiographs or copies of radiographs, for which the facility should obtain a signed-release when transferred; surgical summary; notation when an owner refuses treatment; tentative diagnosis and prognosis if known; any follow-up instructions
Who should record the information:
Technicians should be responsible for compiling the emergency medical record and making sure the client receives it upon discharge.
When to record it:
Since a patient typically spends just a short time in an emergency clinic, the record should be updated in real time at each step.
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