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Video Explaining The Full Examination Of A Dog

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Video Explaining The Full Examination Of A Dog

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Canine General Physical Examination | for clinic owners

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A Veterinarian is medical professional who specializes in the diagnosis, treatment, and prevention of diseases and injuries in animals. They are trained to care for a wide range of animal species, including domestic pets, livestock, zoo animals, and wildlife.

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As someone who enjoys the company of animals I always thought becoming a veterinarian would be a dream job. As I figured that there is paper work that does come with the job. I broke it up into three categories explain what it is, the role and how to make one. With that the importance of paper work and history of the patients life is crucial for a healthy life.

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Medical transcription services can help with transcribing any kind of clinical document, helping to streamline documentation and ensure better patient care. Among the many important documents are the discharge summaries. Professional EHR-integrated transcription services enable hospitals to create comprehensive discharge summaries - vital documents that are often overlooked by hospitals and, as a result, cause a negative impact on the patient's post-discharge care.

Discharge Summaries are Absolutely Essential

Lack of a properly transcribed discharge summary can cause issues since in such cases patients are transferred without any clear instructions - the end outcome is affected and the risk of patient harm is also greater.

Discharge summaries provide clear guidance on how care must be rendered to the patient. Clinicians will have a clear idea of what treatment to administer, when to administer it, and what reaction to expect from the patient. It helps reduce anxiety and stress in workflow which would eventually affect the quality of care provided.

While patient portals and EHRs provide patients direct access to records, many of the physician notes are still concealed in discharge summaries. A complete discharge summary is also proof of the care and concern the hospital shows towards the patient and the steps it takes to ensure the patient has a great follow-up.

Incomplete Discharge Summaries Cause Fragmented Care

Fragmented care and treatment not efficiently coordinated has been one of the major causes of increased healthcare costs and patient harm according to the Health and Medicine Division (HMD). Apparently, even high performing health systems lag behind in the timeliness and transmission of discharge summaries as well as in the content quality. Sharing patient information is a vital aspect of care delivery. Inaccurate or delayed information transfer through the various care levels has a negative impact on re-admission, safety, efficiency as well as other quality dimensions.

Research conducted by the Yale University School of Medicine on heart failure exacerbation patients also states that quick distribution of detailed discharge summary to patients' doctors improved outcomes of patients following a hospital stay and also reduced the chances of them being readmitted within a period of 30 days. In other words, the higher the quality of the discharge summary is, the lesser is the risk of complications which would necessitate readmission.

Essential Factors for Creating Discharge Summaries

Let's look at the three essential aspects of the discharge summary - timeliness, smooth transmission, and content quality:

Timeliness is a very important factor since hospitals must create a summary and provide a copy to the primary care provider of the patient to ensure better care quality. The Yale University School of Medicine research found that nearly 8% of the surveyed facilities did not have discharge summaries ready till 30 days had passed following the discharge.

Transmission must be swift and smooth as well. Hospitals should ensure that they get the summary sent to the right practice or clinician for the next level of care after discharge. This does help in streamlining the recovery of patients while increasing their chances of receiving follow-up care.

There can be no overemphasis on the content quality. Many discharge summaries are shockingly scarce on important details regarding the condition of the patient during discharge, any pending tests to carry out, further medication to be administered, or other follow-up recommendations.

Flawless Discharge Planning

In line with these factors, it would be wise to evaluate the discharge process of your hospital if there are issues in your discharge summaries. It is important to remember that the preparation for a smooth discharge starts right when the patient is admitted. The AHA (American Hospital Association) has brought out a few guidelines that hospitals must follow regarding discharge planning:

To begin with, discharge planning must be based on the sound judgment of doctors, clinicians, nurses and other medical professionals of the care giving team.

It is important to analyze the needs of each patient before you decide on their post-hospital placement following their discharge.

Advanced resources such as EHRs need to be utilized to their full capacity for reducing or streamlining any administrative burden that could arise because of thorough discharge planning.

Clinicians must collect all the required information, while the patient is at the hospital, regarding the choices that must be made for the post-discharge follow up care.

With these steps in place, discharge summaries can be transmitted more efficiently and smoothly. Professional medical transcription services can ensure prompt and accurate creation of these summaries, which will also help hospitals to be legally sound and have a strong record of the care they have provided.

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What is the Importance of Discharge Summaries

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Medical transcription services can help with transcribing any kind of clinical document, helping to streamline documentation and ensure better patient care. Among the many important documents are the discharge summaries. Professional EHR-integrated transcription services enable hospitals to create comprehensive discharge summaries - vital documents that are often overlooked by hospitals and, as a result, cause a negative impact on the patient's post-discharge care.

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Creating a discharge summary for veterinary medicine, it's important to use language that is clear and easy to understand for the pet owner. Additionally, it's important to provide any relevant instructions for the pet owner, such as how to administer medications or care for the pet at home. A well-written discharge summary can help ensure that the pet owner has all the information they need to provide the best possible care for their pet after they leave the veterinary hospital. Key Things to put on a the discharge is pets name, breed, medication or anything that is personal for the patient.

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Discharge summary is   important document for veterinarians for similar reasons as it is for healthcare providers. A well-prepared discharge summary ensures that the veterinarian's recommendations and the pet owner's instructions are clear, complete, and understood. Some of the importance of a discharge summary for veterinarians are Continuity of care, Communication, and Medication Management.

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Discharge instructions are a written summary with a clear diagnosis at the top in everyday language, They summarize what diagnostics were done and what happened List medications – what it is (antibiotic, pain relief, and antacid. With that when to give and when to start

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By T. J. Dunn, Jr., DVM

It is always nice to know what to expect when you visit the veterinarian. Why? Because nobody likes surprises. So what what is going through the doctor's mind when your dog (or cat) is presented.

Let's just say you came in for your pet's routine yearly vaccination. Usually this is a good time for the doctor to take a really close look at your pet -- a good time to do an annual physical exam.

Written notes on the patient's medical chart are absolutely necessary in order to maintain a good medical history. So when the doctor isn't probing and pulling, there will be some written data being recorded. Later this information is transferred to a computerized program that sorts and organizes yearly reminders, prescription data, important patient events or surgeries and billing data.

Computers are an excellent way for the veterinarian to access current information on new techniques, medications and procedures. Plus, as a way to access continuing education references, the computer and Internet have opened up libraries of information on dog (and cat) care.

A good physical exam includes taking the patient's temperature. Normal temperature for a dog or cat varies between 101 and 102.5 degrees; that's a bit higher than our normal temperature. So if you see the veterinarian lift the pet's tail up and come at it with the thermometer, don't be shocked! The temperature is taken rectally and causes no discomfort. Every so often a seemingly healthy pet tips off the veterinarian that something isn't quite right simply by having an elevated temperature.

Skin and coat are really excellent indicators of the pet's health status. Look at this dog's coat and you can see right away that there is something wrong. The coat should be shiny, not brittle and coarse, and the skin should be clean and not greasy and flaky.

The vast majority of skin and coat problems are associated with grain-based diets of poor quality and during the physical exam your veterinarian should inquire about the pet's diet. Two weeks on a meat-based diet and this dog will often look, feel and act much better. (Visit our nutrition section for some good advice on the matter.)

Many types of dermatological problems are avoided if the dog or cat is consuming an optimum diet. In some cases, adding a supplement such as, a mega fatty acid supplement is the key factor in avoiding repeated episodes of hot spots and other skin afflictions.

Your veterinarian should examine both ears, too. Obvious infections and allergies are problems the owner can see, like the infected ear on this dog. But often, deep in the ear canal is where infections can start and if noticed early, can be eliminated before they get to the stage where the ears look like what you see in the photo (on the right).

Many dogs (and cats) suffer from allergies. Skin and ear infections are commonly the result of repeated allergic episodes. The doctor will show you how to clean the ears and prescribe the right medication if signs of an infection are present. Check your dog's (and cat's) ears and look for any signs of disease.

Every good exam includes getting that stethoscope against the chest and listening to the lungs and paying close attention to the heart sounds. Dogs seldom get pneumonia. Much more common are heart rhythm and heart valve problems. The first way to gain information about a dog's (or cat's) heart is to listen. (If your veterinarian seems not to be listening to you while the stethoscope is plugged into his/her ears, don't be insulted!) If any deviation from normal is detected, further workup is a good idea. A cardiac workup usually entails an EKG to assess the electrical activity of the heart and X-rays or an echocardiogram to evaluate the heart's size and shape.

A careful evaluation of the abdomen must be a part of the physical exam. Every veterinarian has made surprising discoveries while examining "normal" dogs (and cats). Many owners were shocked to find out that their pet had only one normal kidney, or was harboring an undiscovered tumor or was pregnant! Bladder stones, for instance, can be discovered during a routine physical exam. So in addition to feeling what's on the outside of the pet, what's inside is just as important.

Every good physical exam must include a look into the pet's mouth -- that is if the pet is willing! Oral hygiene (see our article on dentistry) is one of the most overlooked aspects of pet health care. The mouth can harbor infected gums, loose teeth, objects stuck between teeth, tumors and all sorts of other surprises. And often the pet shows no signs of discomfort from even serious oral abnormalities. Older dogs (and cats) especially may have oral hygiene difficulties that would vastly improve if dental and oral treatment was instituted. Be sure the veterinarian takes a look!

Although the eyes may not need a thorough exam where the veterinarian inspects the interior of the eye with special instruments, at least a close inspection of the visible eye structures and lids is a part of a complete physical exam. Early cataract formation may be detected, any haziness on the surface of the cornea can be detected and inflammation of the surrounding eye structures can be assessed. The most common difficulties are simple irritations that result from pollen, dust and contact with grasses.

Finally, the paws and toenails should be examined, and any really long nails should be clipped shorter (see How to Trim Toenails). Pad injuries are usually quick to heal and it is a wonder that dogs (and cats) don't cut and puncture their pads more often than they do.

Now that your pet has had a head-to-toe examination, you and the veterinarian will feel more confident that the pet is healthy. Now the challenge is to keep the pet well!

Image: Courtesy of AVMA

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The Physical Exam: What to Expect at the Veterinarian's Office

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By T. J. Dunn, Jr., DVM It is always nice to know what to expect when you visit the veterinarian. Why? Because nobody likes surprises. So what what is going through the doctor's mind when your dog (or cat) is presented. Let's just say you came in for your pet's routine yearly vaccination.

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August 3rd, 2017

Knowing your pet???s entire medical history can be hard, as many will have multiple visits to the veterinarian???s over their lifetime. Having a copy of your dog or cats vet records is important in determining what type of care and treatment may be needed.

If you do not have your pets medical record, you should ask you vet straight away. This is particularly important if you are moving locations, changing vets or changing owners (either you???re handing your pet over to someone else, or receiving a pet from someone).

What should be included?

If you are getting an older dog from someone it is imperative that you ask them for a complete vet history ??? or at the very least, a record of when they received their essential vaccinations. This will allow you and your vet to know if they a prone to any diseases or whether or not they need vital vaccinations immediately.

This complete medical history that you have should include a record of every veterinary visit from the pet birth onwards. On these records, the vet should have filled out the date of the visit, the basics of the pet (these include the length, weight, vaccination history), surgeries, medications prescribed, and hospital visits.

The vet history will also include blood tests showing both the recording of the blood test being performed and the results of these tests.

How to get a copy

There are a number of ways you can receive your pets vet history. If you have had your dog since birth and are changing vets or moving location, your existing vet will be able to give you a full record. Before changing vets, be sure to grab your old vets contact information just in case your new vet has some questions to clarify your pet???s history.

If you???re adopting a pet from a shelter or a friend, a copy of their history may be tougher to get. A shelter will have as much medical history as possible, however many dogs that come to them will have no documentation and will therefore not have any medical reports. If you???re getting a pet from a friend or someone else, you can ask them directly for the vet history or ask for their vet to send it to your vet.

Having the appropriate vet records on hand not only allow you to know what your pet has been through, it also makes it easier for the vet to assess them. They will be able to see what medication they have been given or operations they have had in the past which will determine how they will go about treating the pet this time around.

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Why vet histories are so important | Petplan Blog

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August 3rd, 2017 Knowing your pet???s entire medical history can be hard, as many will have multiple visits to the veterinarian???s over their lifetime. Having a copy of your dog or cats vet records is important in determining what type of care and treatment may be needed.

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When someone takes their pet to a veterinary clinic for a check up. It is broken down into several steps each one having a valuable part in order the animals overall health. these steps are observing the animal from a distance, noting its overall appearance, posture, behavior, and any signs of distress or discomfort. Vital Signs: The veterinarian will then take the animal's vital signs, including its temperature, heart rate, respiratory rate, and blood pressure. Head and Neck- examining the animal's head and neck, looking for signs of abnormalities, such as lumps, bumps, or discharge from the eyes, nose, or ears. Looking at the  animal's body, looking for signs of abnormalities in the skin, fur, muscle tone, and weight. Then the Limbs will  be examine looking for signs of swelling, pain, or stiffness. Abdomen: Checking the palpate the animal's abdomen, feeling for any abnormalities or signs of pain. Finally, Genitalia and Anus: The veterinarian will examine the animal's genitalia and anus, looking for signs of infections or abnormalities and checking its temperature.

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Regular physical exams can help detect health issues early, which can improve the chances of successful treatment and recovery. Here are some reasons why physical exams are important for pets: Early detection of health problems: Physical exams can help veterinarians detect early signs of health problems in pets. This can include dental disease, skin infections, arthritis, heart disease, cancer, and more. Early detection of these conditions can help ensure that the pet receives prompt and appropriate treatment, improving the chances of a successful outcome. Prevention: Physical exams can also help prevent health problems from occurring in the first place. Veterinarians can provide preventative care, such as vaccinations, parasite control, and nutritional counseling, during a physical exam. This can help keep pets healthy and reduce the risk of future health issues.

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Physical exam is a comprehensive examination that veterinarians use to evaluate the overall health and well-being of an animal. During a physical exam, the veterinarian will assess the animal's body systems, including: Vital signs: The veterinarian will measure the animal's heart rate, respiratory rate, temperature, and blood pressure. Eyes, ears, and nose: The veterinarian will examine the animal's eyes, ears, and nose for signs of infection, inflammation, or other abnormalities. Mouth and teeth: The veterinarian will examine the animal's mouth and teeth for signs of dental disease, oral tumors, or other issues. Kin and coat: The veterinarian will examine the animal's skin and coat for signs of parasites, infections, or other skin conditions. Musculoskeletal system: The veterinarian will evaluate the animal's joints, muscles, and bones for signs of injury or disease. Abdomen: The veterinarian will palpate the animal's abdomen to check for any abnormalities in the internal organs. Neurological system: The veterinarian will evaluate the animal's nervous system by checking their reflexes, coordination, and mental state.

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How to Write a Record of a Patients History

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How to Write a Record of a Patients History

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When writing records veterinarians use language that is familiar to all veterinarians with abbreviations that are commonly known.  You should write medical records in such a way that any veterinarian can read the records and understand what is going on enough to continue with the care and treatment of that patient. Records Kept in Confidence

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Veterinarians use Medical History Record as a timeline for seeing the status of the patient health and monitoring the changing overtime. While serving as a timeline it will also provide the potential health risks such as allergies, illness, injuries. It can help create accurate diagnosis like previous vaccinations and help rule out certain diseases. All together it could lead to treatment plans and with the timeline, and overall history it can show treatment plans. This can include medication, prescription, appointments and changes in lifestyle.

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In simple terms a "patient" for veterinarian is an animal or commonly a pet. Having a record of that pets history is important it shows its medical history, illness, surgeries and vaccinations.