[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-194458-105":53,"doc-detail-194458-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","patient-medical-record-inspection-guidance","Patient Medical Record Inspection Guidance","","Guidance for inspecting animal patient medical records against compliance criteria. Covers required documentation elements including identification details, medical history, presenting complaint, immunization records, diagnostic procedures, diagnosis, treatment plans with medication and dosage, and legibility. Includes structured assessment areas for age, sex, weight, temperature and systematic physical examination findings, plus abnormal notes and treatment plan documentation. Also specifies pre-surgical assessment timing and record-keeping responsibilities for medications and client instructions.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/patient-medical-record-inspection-guidance/194458/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/patient-medical-record-inspection-guidance/194458.png","ImageObject",442,249,{"name":88,"@type":89},"Oliver","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-08","2026-09-03",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",7,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What basic information must be documented in the patient’s medical record?","Question",{"text":109,"@type":110},"The record should include patient identification details (including sex and weight), medical history and presenting complaint, immunization records, diagnostic procedure performed, diagnosis, and a treatment plan with medication and dose.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What should be included in a pre-surgical assessment and when must it be completed?",{"text":114,"@type":110},"A pre-surgical assessment must be provided within 12 hours prior to anesthetic administration. The documentation should include the reason for anesthesia and a brief exam, and be expanded if it is the only exam related to that anesthetic episode.",{"name":116,"@type":107,"acceptedAnswer":117},"What record-keeping responsibilities apply to medications and controlled substances?",{"text":118,"@type":110},"Veterinarians must maintain accurate medication records including strength, dosage, and quantity of all medications used or prescribed, and ensure controlled substance entries in patient records match drug logs. Client instructions for storage and administration of drugs should also be provided.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},194458,1788439252,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":126,"read_time":9},8796095461610,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","|  | Complies | Does Not Comply | N/A |\n| --- | --- | --- | --- |\n| Identification of the [patient‐](patient‐ ie. sex)[ ie. sex](patient‐ ie. sex), weight, breed |  |  |  |\n| The patient's medical history; presenting complaint |  |  |  |\n| Immunization records |  |  |  |\n| Diagnostic procedure performed |  |  |  |\n| Diagnosis |  |  |  |\n| Treatment plan: including medication and dose |  |  |  |\n| Legible |  |  |  |\n\n\n| Age: | .\u003Cbr>Sex: | Weight: | Temp(F): |\n| --- | --- | --- | --- |\n| General Appearance:\u003Cbr>N A NE | Oral Cavity:\u003Cbr>N A NE | Mucous Membranes:\u003Cbr>N A NE | Eyes:\u003Cbr>N A NE |\n| Ears:\u003Cbr>N A NE | Cardiovascular:\u003Cbr>N A NE | Respiratory:\u003Cbr>N A NE | Gastrointestinal:\u003Cbr>N A NE |\n| Musculoskeletal:\u003Cbr>N A NE | Lymph nodes:\u003Cbr>N A NE | Urogenital:\u003Cbr>N A NE | Integumentary:\u003Cbr>N A NE |\n| Nervous System:\u003Cbr>N A NE | Hydration:\u003Cbr>N A NE | HR \u003Cbr>RR  | BP  |\n| Abnormal Notes: |  |  |  |\n| Treatment Plan: |  |  |  |\n\n\n| 5.8. b. A veterinarian shall provide every animal with a pre‐surgical assessment within 12 hours prior to the administration of an anesthetic, and the results of this examination shall be noted in the patient's medical record. Examination should include reason for anesthesia along with a brief exam. Purpose of the exam is to assess the animal before anesthesia/surgery if a prior exam has been completed related to the need for anesthesia. However, if this is the only exam that occurs related to the anesthetic episode, a more complete exam should be documented as above. Include treatment plan and any other necessary client information and follow up. | Complies | Does Not Comply | N/A |\n| --- | --- | --- | --- |\n\n\n| Age: | Sex: | Weight: | Temp(F): |  |\n| --- | --- | --- | --- | --- |\n| General Appearance:\u003Cbr>N A NE | Mucous Membranes:\u003Cbr>N A NE | Cardiovascular:\u003Cbr>N A NE | Respiratory:\u003Cbr>N A | NE |\n| Nervous System:\u003Cbr>N A NE | Hydration:\u003Cbr>N A NE | HR \u003Cbr>RR  |  |  |\n| Abnormal Notes: |  |  |  |  |\n| Treatment Plan: |  |  |  |  |\n\n\n| 5.3.c. The veterinarian shall be responsible for maintaining accurate records in the patient's medical history which shall include strength, dosage and quantity of all medications used or prescribed | Complies | Does Not Comply | NA |\n| --- | --- | --- | --- |\n| 5.3.d. The veterinarian shall provide appropriate instruction to clients on the storage and administration of drugs. |  |  |  |\n| Controlled substance in patient records match the drug logs. |  |  |  |","cbCaibdvb4popnEI","https://ap.wps.com/l/cbCaibdvb4popnEI","pdf",110955,"English","# Compliance checklist\n## Required record sections\n## Physical assessment fields\n## Medication and record-keeping requirements","[{\"question\":\"What basic information must be documented in the patient’s medical record?\",\"answer\":\"The record should include patient identification details (including sex and weight), medical history and presenting complaint, immunization records, diagnostic procedure performed, diagnosis, and a treatment plan with medication and dose.\"},{\"question\":\"What should be included in a pre-surgical assessment and when must it be completed?\",\"answer\":\"A pre-surgical assessment must be provided within 12 hours prior to anesthetic administration. The documentation should include the reason for anesthesia and a brief exam, and be expanded if it is the only exam related to that anesthetic episode.\"},{\"question\":\"What record-keeping responsibilities apply to medications and controlled substances?\",\"answer\":\"Veterinarians must maintain accurate medication records including strength, dosage, and quantity of all medications used or prescribed, and ensure controlled substance entries in patient records match drug logs. Client instructions for storage and administration of drugs should also be provided.\"}]","Patient Medical Record Inspection Guidance | PDF"]