Veterinary Examination Template

What is a Veterinary Examination?

A veterinary examination (also called an intake exam, initial assessment, or comprehensive exam) is a thorough evaluation performed by a veterinarian when assessing a patient. It establishes the patient's health status, identifies problems, and creates a foundation for treatment decisions.

The veterinary examination is critical for several reasons:

Baseline Documentation: Creates a health record that can be referenced for future visits
Problem Identification: Systematically evaluates all body systems to identify issues
Legal Protection: Provides documentation of findings and clinical decision-making
Client Communication: Helps explain findings and recommendations to pet owners
Continuity of Care: Enables other veterinarians to understand the case if needed

Species Considerations Documentation requirements vary by species. Canine and feline exams have similar structures, while equine, avian, and exotic patients require species-specific approaches to history, physical exam, and normal value interpretation.

What Does a Veterinary Examination Include?

A complete veterinary examination follows a structured format that ensures thorough assessment. Each section builds on the previous to create a comprehensive picture of the patient's health.

1. Signalment

Essential identifying information including species, breed, age, sex, reproductive status (intact/altered), color/markings, weight, and microchip number if applicable. This information affects normal values, disease predispositions, and treatment choices.

2. History and Presenting Complaint

Owner-reported information about why they're bringing the pet in, duration and progression of symptoms, appetite, water intake, urination, defecation, activity level, and any home treatments attempted. Also includes vaccination history, diet, and current medications.

3. Physical Examination

Systematic head-to-tail assessment including vitals (temperature, heart rate, respiratory rate), body condition score, and evaluation of all body systems: eyes, ears, nose, mouth/teeth, lymph nodes, cardiovascular, respiratory, abdominal, musculoskeletal, neurological, and integumentary.

4. Diagnostics

Laboratory tests, imaging, and other diagnostics ordered based on history and exam findings. Common tests include CBC, chemistry panel, urinalysis, fecal examination, radiographs, and ultrasound. Document results and interpretation.

5. Assessment

Clinical interpretation of findings including primary diagnosis, differential diagnoses (ranked by likelihood), and prognosis. This demonstrates your clinical reasoning and guides treatment decisions.

6. Plan

Treatment recommendations including medications (with dose, route, frequency, duration), procedures, dietary recommendations, activity restrictions, and follow-up schedule. Also includes client education about the condition and what to watch for at home.

Complete Veterinary Examination Template

Below is a comprehensive veterinary examination template. You can use this as a reference for manual documentation or let SOAP Note Buddy auto-generate examinations in your PIMS.

Signalment

Species

[Canine/Feline/Equine/Avian/Exotic]

Breed

[Breed]

Age

[Age]

Sex

[M/F, Intact/Neutered/Spayed]

Weight

[Weight in kg or lbs]

Color/Markings

[Description]

Microchip Number

[Microchip # if applicable]

History

Presenting Complaint / Reason for Visit

[Owner's primary concern, symptoms observed, duration, progression. Include what prompted the visit today.]

History of Present Illness

[Detailed description of current problem including onset, duration, progression, frequency, severity. Any treatments attempted at home? Response to those treatments?]

Daily Habits

Appetite

[Normal/Decreased/Increased/Absent]

Water Intake

[Normal/Decreased/Increased]

Urination

[Normal/Increased/Decreased/Straining]

Defecation

[Normal/Diarrhea/Constipation]

Activity Level

[Normal/Decreased/Increased]

Vomiting/Regurgitation

[None/Frequency if present]

Diet

[Brand, type (dry/wet/raw), amount, feeding schedule, treats]

Environment

[Indoor/Outdoor/Both, other pets in household, recent changes, travel history]

Past Medical History

[Previous illnesses, surgeries, hospitalizations, known conditions]

Vaccination Status

[Current vaccines and dates: Rabies, DHPP/FVRCP, Bordetella, Leptospirosis, etc.]

Parasite Prevention

[Heartworm, flea/tick prevention - product and compliance]

Current Medications/Supplements

[Name, dose, frequency, duration]

Known Allergies

[Drug allergies, food allergies, environmental allergies]

Physical Examination

Vital Signs

Temperature

[Temp F/C]

Heart Rate

[HR bpm]

Respiratory Rate

[RR breaths/min]

Body Condition Score

[BCS /9]

Muscle Condition Score

[MCS - Normal/Mild/Moderate/Severe loss]

Pain Score

[Pain scale if applicable]

General Appearance

[Mentation (BAR, QAR, dull, obtunded), hydration status, body posture, gait, overall demeanor]

Eyes (OU/OD/OS)

[Pupils (PLR), cornea, conjunctiva, sclera, lens, discharge, Schirmer tear test if indicated, IOP if indicated]

Ears (AU/AD/AS)

[Pinnae, external canals, discharge, odor, pain, otoscopic findings]

Nose/Nasal

[Discharge, symmetry, airflow, depigmentation]

Oral Cavity/Dental

[Mucous membranes (color, moisture, CRT), dental grade, calculus, gingivitis, missing teeth, masses, tongue, tonsils, palate]

Lymph Nodes

[Mandibular, prescapular, axillary, inguinal, popliteal - size, symmetry, texture]

Cardiovascular

[Heart rate, rhythm, murmur (grade I-VI/VI, PMI), pulse quality, pulse deficits, femoral pulses]

Respiratory

[Respiratory rate, effort, lung sounds (normal, crackles, wheezes, decreased), tracheal palpation, cough reflex]

Abdominal

[Palpation findings: organomegaly, masses, pain, fluid, GI contents, bladder size/expression]

Urogenital

[External genitalia, mammary glands, vulvar discharge, testicular exam if intact male, prostate if indicated]

Musculoskeletal

[Gait, lameness (grade, limb), joint palpation, range of motion, muscle mass, pain on manipulation, orthopedic tests]

Neurological

[Mentation, gait/posture, postural reactions, spinal reflexes, cranial nerves, pain perception if indicated]

Integumentary

[Coat quality, alopecia, lesions (location, type), parasites, skin turgor, masses]

Diagnostics

Laboratory Tests Performed

[CBC, Chemistry, Urinalysis, Fecal, Heartworm test, FeLV/FIV, etc. - list tests and results]

Imaging

[Radiographs, Ultrasound, CT, MRI - findings and interpretation]

Other Diagnostics

[Cytology, culture, biopsy, ECG, blood pressure, etc.]

Assessment

Primary Diagnosis

[Main diagnosis based on findings]

Differential Diagnoses

[List of differential diagnoses in order of likelihood: 1. [Most likely] 2. [Second most likely] 3. [Third most likely]]

Clinical Summary

[Summary of clinical reasoning connecting history, exam findings, and diagnostics to your assessment]

Prognosis

[Excellent/Good/Fair/Guarded/Poor - with explanation]

Plan

Treatment Administered Today

[Fluids, injections, procedures performed during visit]

Medications Prescribed

[Drug name, dose, route, frequency, duration, number dispensed Example: - Clavamox 125mg PO q12h x 14 days - #28 tablets dispensed - Cerenia 16mg PO q24h x 4 days PRN for nausea - #4 tablets dispensed]

Dietary Recommendations

[Diet changes, feeding instructions, food restrictions]

Activity Restrictions

[Exercise restrictions, cage rest, no swimming, etc.]

Client Education

[What was discussed with owner about the diagnosis, treatment, expectations, and home monitoring]

Warning Signs to Watch For

[Symptoms that should prompt immediate contact or return visit]

Follow-Up

[Recheck timing, additional diagnostics planned, referral if indicated]

Declined Recommendations

[Any recommended diagnostics or treatments owner declined, with documentation that risks were discussed]

Signatures

Veterinarian

[Name, DVM]

License Number

[License #]

Date

[Date]

Time

[Time]

Tips for Veterinary Examination Documentation

Thorough documentation protects you, helps your colleagues, and ensures continuity of care. Here are tips for better veterinary examination records.

Be Systematic

Always examine patients in the same order - head to tail, inside to out. This ensures you don't miss anything and creates consistent documentation that's easy to review.

Document Abnormals AND Normals

Don't just write "WNL" for everything. Document key normal findings that were specifically assessed. "Lungs clear and eupneic" is more informative than "Resp: WNL" and shows you actually auscultated.

Use Standard Terminology

Use consistent abbreviations and scales. Body condition score should always be on the same scale (1-9 or 1-5). Heart murmurs should be graded I-VI/VI with PMI location. This allows tracking over time.

Connect History to Findings

Your assessment should demonstrate how history and physical findings led to your diagnosis. "Given 3-day history of vomiting, palpable mid-abdominal pain, and radiographic evidence of dilated small intestinal loops, suspect small intestinal obstruction."

Document Client Conversations

Record what you discussed with the owner, especially regarding prognosis, treatment options, and any declined recommendations. This protects you if questions arise later.

If You Didn't Document It, It Didn't Happen In veterinary medicine as in human medicine, your medical record is your legal protection. Thorough documentation demonstrates the standard of care you provided and supports your clinical decisions.

How SOAP Note Buddy Helps with Veterinary Examinations

Veterinary examinations are comprehensive and time-consuming to document. Between appointments, emergencies, and surgeries, documentation often gets pushed to after hours. SOAP Note Buddy helps you stay caught up.

Generate Complete Examinations in Minutes

SOAP Note Buddy uses AI to dramatically speed up your examination documentation. Enter your patient's key findings and the AI generates a complete examination record in your PIMS.

What SOAP Note Buddy Does:

Auto-Detects Your PIMS Fields: Works with eVetPractice, Cornerstone, AVImark, Shepherd, and any web-based system
Species-Aware Content: Generates appropriate terminology and normal values for canine, feline, equine, and exotic patients
Understands Vet Terminology: BCS, heart murmur grades, dental grades, lameness scales, and common diagnoses
Creates Complete Records: From signalment through plan, with all required sections
HIPAA Compliant: Client information is protected with automatic PHI removal

What used to take 10-15 minutes now takes 2-3 minutes of review and customization. Stay caught up during clinic hours instead of documenting at home.

Try Free for 3 Days

Frequently Asked Questions

What should be included in a veterinary examination?

A comprehensive veterinary examination includes signalment (species, breed, age, sex, weight), presenting complaint, medical history, vaccination status, systematic physical exam (vitals, body condition score, all body systems), diagnostic findings, assessment with differential diagnoses, and a detailed treatment plan with client instructions.

How long should a veterinary exam take to document?

A typical veterinary examination takes 15-30 minutes for the patient visit depending on complexity. Documentation can take an additional 10-15 minutes if done manually. Using AI documentation tools like SOAP Note Buddy can reduce documentation time to 2-3 minutes, allowing you to complete records between patients.

What is signalment in veterinary medicine?

Signalment refers to the identifying characteristics of an animal patient, including species (canine, feline, etc.), breed, age, sex, reproductive status (intact or altered), color/markings, and weight. This information is essential for appropriate diagnosis and treatment as many conditions have breed or age predispositions.

What body systems should be examined in a vet physical?

A complete veterinary physical exam should assess: general appearance and mentation, eyes, ears, nose/mouth/throat, cardiovascular system, respiratory system, gastrointestinal system, urogenital system, musculoskeletal system, neurological system, integumentary system (skin/coat), and lymph nodes. The depth of each system assessment depends on the presenting complaint.

How do you document body condition score?

Body condition score (BCS) is typically documented on a 9-point scale (1-9) or 5-point scale. For the 9-point scale: 1-3 is underweight, 4-5 is ideal, 6-7 is overweight, 8-9 is obese. Always document both the score and scale used (e.g., "BCS 6/9") so the record is clear for future visits.

How can AI help with veterinary examinations?

AI documentation tools like SOAP Note Buddy can significantly reduce examination documentation time. Enter your exam findings and the AI generates a complete examination record including all sections. You review and customize the output, saving 10+ minutes per exam. This allows you to complete documentation between patients instead of staying late.