There are numerous common medical note items that come setup “out of the box” with HQ. You can delete or edit these as you like in Settings > Medical Notes. For your reference, they are included here. You can of course create your own also.
Here is a Word version if you’d like to share them with others in your office for review.
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ITEM TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Add item
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DECLINED SURGERY TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Already Been Sterilized
The patient was declined for surgery as there was an indicator such as a tattoo or scar present that indicated your pet had already been sterilized.
Gastro-Intestinal Issue (Non-Parvovirus)
Your pet was declined surgery due to having severe diarrhea. Causes of severe diarrhea include intestinal parasites and viral/bacterial infections. We recommend that you seek the advice of a full-service veterinarian for guidance in a diagnostic workup to assess the health of your pet.
Overweight
Your pet was declined surgery because s/he is overweight, a condition that increases the risk of surgical complications. This condition is normally correctable, so we recommend that you seek the guidance of a full-service veterinarian to assist you in designing a weight loss program for your pet.
Underweight
Your pet was declined surgery because s/he is underweight, a condition that increases the risk of anesthetic complications. This can be caused by a disease process or may simply mean that your pet needs a higher caloric intake. We recommend that you seek the advice of a full-service veterinarian to evaluate the health status of your pet and for guidance in addressing this normally correctable condition.
Brachycephalic
Your pet is brachycephalic, meaning s/he has a short nose, narrow nasal openings, and thickened throat tissue. Some brachycephalic pets breathe without problems; however, your pet displayed signs of breathing difficulty on initial exam. Since these breathing problems can worsen under anesthesia, your pet was declined for surgery. We recommend that you follow up with a full-service veterinarian for further assessment and spay/neuter surgery.
Too Small
Your pet was declined surgery because s/he did not weigh enough to safely anesthetize. We recommend that s/he weigh at least three pounds.
High Risk Waiver – Owner Declined
One of our medical professionals contacted you and discussed a concern about your pet’s health that was discovered on physical exam that could impact the outcome of your pet’s surgery. You declined having surgery performed at this time. We recommend that you seek the assessment of a full-service veterinarian to evaluate your pet’s issue.
BMBT Test (Failed)
Your dog was declined surgery due to failing a Buccal Mucosal Bleeding Time (BMBT) test, an indicator that your pet is suspect of having a blood clotting disorder called von Willebrand disease. The Doberman Pinscher (or mix thereof) is an at-risk breed for this condition. We recommend that you seek evaluation by a full-service veterinarian for further investigation of this issue.
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PRESCRIPTION TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Add item
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DRUGS / MEDICINES GIVEN TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Add item
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BIOLOGICAL TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Cryptorchid – Unilateral
Cryptorchid – Bilateral
Hernia – Repaired
Hernia – Not Repaired
In Heat
Your pet was in heat at the time of surgery. Separate her from intact males for a minimum of ten days to allow the internal surgical sites to heal.
Pre-Scrotal Neuter
Your pet received a neuter surgery (castration). The incision was placed directly in front of the scrotum. Unless otherwise noted, there are no sutures to remove.
Pregnant
Your pet was pregnant at the time of surgery and may take longer to recuperate. Strictly follow our post-operative instructions to ensure that she has an uneventful healing period.
Pyometra
Your pet was found to have a pyometra (uterine infection) during her spay. The infected uterus and the ovaries were removed, which is often curative when the pyometra is found early. Antibiotics may have been prescribed to eliminate any remaining infection.
BMBT Test (Passed)
Because your dog is a Doberman Pincher (or a mix of), a breed which is at-risk for a blood clotting disorder called von Willebrand disease, we performed a Buccal Mucosal Bleeding Time (BMBT) Test to assess blood clotting function. Your pet passed and qualified for surgery. BE ADVISED that this test is a screening tool and does not negate the at-risk status of the breed and the potential of developing clinical disease in the future.
Lactating
Your pet was lactating (producing milk) at the time of surgery. If she has recently given birth and is still nursing, she should be returned to her litter as soon as possible. If your pet has not recently given birth, lactation is a result of “false pregnancy.” In this case the spay surgery is curative, but it can take several weeks for the clinical signs/lactation to resolve.
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INCISION ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Bruising Expected
Expect bruising near the surgical incision. This should resolve on its own within 14 days.
Clipper Abrasion (burn)
Your pet’s skin became irritated from clipping/shaving the hair required to perform surgery. We treated the affected area and the irritation should resolve within ten days. Monitor the area and contact us with any concerns.
Cold Compress Recommended
A cold compress applied to your pet’s swollen site will help control pain, reduce swelling, and make your pet more comfortable. Apply an ice pack (a bag of frozen peas works well) wrapped in a clean cloth against the affected area for up to 20 minutes, 2-3 times a day for two days. DO NOT place ice packs directly on skin.
Staples
Your pet received skin staples to close the surgical incision, and they will need to be removed in 10-14 days, either by us or by any full-service veterinarian.
Warm Compress (dry) Recommended
A dry warm compress applied to your pet’s swollen site will aid in healing and make your pet more comfortable. Heat a washcloth with hot water. It needs to be very warm, but if it is too hot for your face, it is too hot for your pet. Place the washcloth in a plastic bag and hold it against the affected area for up to 20 minutes, 2-3 times a day for three days.
Warm Compress (wet) Recommended
A damp warm compress applied to your pet’s swollen site will aid in healing and make your pet more comfortable. Heat a washcloth with hot water and wring it out so it is damp, not dripping wet. It needs to be very warm, but if it is too hot for your face, it is too hot for your pet. Hold the washcloth against the affected area for up to 20 minutes, 2-3 times a day for three days.
Swelling Expected
Your pet has mild swelling at their incision site. This will often resolve on its own if s/he is not allowed to lick/chew/scratch and is activity restricted. Please contact us if the swelling does not resolve within ten days, if it gets worse, or if you notice an increase in redness or discharge from the incision.
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GI ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Diarrhea
Your pet has diarrhea. Possible causes of loose stools are stress, diet change or food indiscretion, and intestinal parasites. If this problem persists, we recommend that your pet be examined by a full-service veterinarian for assessment of your pet’s gastrointestinal health.
Nauseous
Your pet became nauseous after surgery. This is a common occurrence. S/he was evaluated and was treated if needed. If your pet continues to display mild signs of nausea (drooling, vomiting infrequently) for more than 24 hours after returning home, or if the signs of nausea rapidly escalate to severe at any time within the 24 hours, please contact us.
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HEAD ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Ear Issue – Right Ear
Ear Issue – Left Ear
Ear Issue – Both Ears
Eye Issue – Right Eye
Eye Issue – Left Eye
Eye Issue – Both Eyes
Mouth Issue
Physical exam revealed that your pet has mouth concerns. We recommend that your pet be examined by a full-service veterinarian for assessment of your pet’s oral health.
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SKIN ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Skin Issue
Physical exam revealed that your pet has skin concerns. Possible causes of skin issues include bacterial or yeast infections, allergies, and external parasites (fleas/ticks/mites). We recommend that your pet be examined by a full-service veterinarian for assessment of the health of your pet’s skin.
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PARASITES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Fleas/Ticks
Physical exam revealed that your pet has fleas and/or ticks. These parasites cause skin issues and carry disease. We recommend that you consult a full-service veterinarian for recommendations on the control and prevention of external parasites.
Fleas
Physical exam revealed that your pet has fleas. These parasites cause skin issues and carry disease. We recommend that you consult a full-service veterinarian for recommendations on the control and prevention of external parasites.
Ticks
Physical exam revealed that your pet has ticks. These parasites cause skin issues and carry disease. We recommend that you consult a full-service veterinarian for recommendations on the control and prevention of external parasites.
Heartworm Positive
Your pet tested positive for heartworms; a parasite carried by mosquitoes that results in worms living in the heart. We recommend that you consult a full-service veterinarian to discuss treatment and prevention options for your pet.
Tapeworms
Physical exam revealed that your pet has tapeworms, an intestinal parasite visible to the naked eye. We recommend that you consult a full-service veterinarian for recommendations on the control and prevention of intestinal parasites.
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WEIGHT ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Overweight
Physical exam revealed that your pet is overweight. This condition is normally correctable, so we recommend that you seek the guidance of a full-service veterinarian to assist you in designing a weight loss program for your pet.
Underweight
Physical exam revealed that your pet is underweight. This condition is normally correctable, so we recommend that you seek the guidance of a full-service veterinarian to evaluate the health status of your pet.
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SICK TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Upper Respiratory Issue
Physical exam revealed that your pet is showing clinical signs suggestive of an upper respiratory infection (URI). These include sneezing, coughing, nasal discharge, eye discharge, and congestion. We recommend that your pet be examined by a full-service veterinarian for assessment of your pet’s respiratory health.
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BODY ISSUES TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Body Composition Score – 1/9
Body Composition Score – 2/9
Body Composition Score – 3/9
Body Composition Score – 4/9
Body Composition Score – 5/9
Body Composition Score – 6/9
Body Composition Score – 7/9
Body Composition Score – 8/9
Body Composition Score – 9/9
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RECHECK NEEDED TRIGGERED NOTES
When this item is added to a patient
Then this text will print in “External Client Communication” field
Recheck Needed
Thank you for returning with your pet so that we could evaluate your medical concern. To ensure successful healing, your pet’s activity must be restricted for at least ten days (or until a follow-up exam by a doctor releases your pet’s restriction). This means no running, swimming or jumping. Confine all pets to a small area when not supervised and walk dogs on a leash.
