There are dozens of medical record-keeping software systems in use throughout the veterinary industry. And for each individual system there are dozens of methods and versions of utilization specific to each clinic. The veterinary industry, like most other health care professions, has yet to find a uniform method for recording medical treatment and recommendations.
Your ability to interpret previous medical records, institute necessary treatment, and leave records that ensure continuity of care is an indispensable trait in a relief veterinarian and one that’s not as simple as it might seem.
Be aware that as a relief professional, your records leave a lasting and legal representation of your work. You may never be notified if one of the cases you see on a relief shift goes to court. Your medical care, recommendations and your decision-making process are likely to be only represented by your SOAP notes.
Below are a few “FYIs” that might make dealing with record-keeping in a new clinic a bit less stressful.