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Record what changed after a vet visit

Before you leave the clinic, check you have written instructions and know when to call. The same day, write what the vet changed, where those instructions are, and who does each next step by when. Your note is the household plan beside the clinic’s instructions, not a rewrite of them.

By Sassi M. · Updated · Sources

Keep the clinic’s instructions

Save the paper or the file the clinic gave you, and write down where it is. Do not retype medication directions from memory. After anesthesia or surgery, AAHA’s anesthesia discharge guidance says those instructions should cover possible complications and when to call the vet.1 For any other visit, use the instructions that clinic gave you. The details will not match an anesthesia discharge, and they should not be borrowed from one.

What to write the same day

Give each next step one person and one date. When medication instructions change, archive the old schedule so it cannot be used by mistake. The FDA’s page on medication errors says to follow the label you were given.3 Mark each dose on the printable medication log.

The same-day note
What to writeUseful detail
Where the instructions areThe file or paper the clinic handed you.
Medication that changedCopied from those instructions, not from memory.
What to watchWhat the clinic asked you to notice at home, and the signs it said to call about.
Who does the next stepOne person, and a date.
What is still openA result, a refill, a recheck, or a question.
PhotosDate each one. Note what it shows, such as the incision or the leg.

Photos and updates

After surgery, the American College of Veterinary Surgeons says periodic photos of the incision help document healing, and that questions or changes should be reported rather than saved for the recheck.2 Its list of reasons to call includes increasing redness, swelling, discharge, or opening of the incision, poor appetite that lasts, and trouble urinating. Toronto Humane Society’s spay and neuter instructions also say to check the incision daily and to send a photo with any concern.4 Use the list your own clinic gave you, since it fits the procedure your pet had.

A completed plan

Example notes for Pepper. The clinic’s file stays the clinic’s file. The note only says what the household will do next.

Pepper’s visit follow-up

Clinic instructions: discharge PDF saved in Pepper’s visit folder.

Medication change: new instructions copied from the label. The older schedule is archived.

Tonight: Jordan will write down appetite and energy.

Friday: Sam will call the clinic if the lab result has not arrived.

July 29: recheck booked.

Open question: which changes should go in the next update to the clinic?

Copy a follow-up note

Fill this in from the clinic’s written instructions. Questions for the next call are in Questions to ask your vet.

Follow-up plan

Show the note
PET:
VISIT DATE:
CLINIC:
VISIT REASON:

OFFICIAL INSTRUCTIONS
Where they are saved:
Medication changes copied from the instructions:

WATCH AND RECORD
What the clinic asked you to notice:
How it will be written down:
Who is responsible:
Signs the clinic said to call about:
Photos saved to:

NEXT STEPS
Action:
Who:
Date:
Status:

FOLLOW-UP
Recheck date:
Expected result or callback:
How to reach the clinic:
Open question:

Read next

What to bring to a vet appointment

The packing list for a vet appointment. It covers medication labels, recent records, photos, and a short note to copy.

CovePet keeps what the vet said and what changed after, dated, on the same record. Coming soon to iPhone, web, and Android.

Sources

  1. Phase 3: Return Home, American Animal Hospital Association
  2. Postoperative Care After Surgery: What Animal Owners Should Expect, American College of Veterinary Surgeons
  3. Veterinary Medication Errors, U.S. Food and Drug Administration
  4. Spay/Neuter Post-Operative Instructions, Toronto Humane Society

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