Often, when observing, physically assisting, or listening remotely during a pet exam, there can be a lot of extraneous content that does not need to be included in the SOAP. When taking notes, listen for clear directives from the veterinarian, or any descriptive language that can be included about the pet. It is ok to clarify directions or notes with the veterinarian if available.

 

Things to listen for include:

• Correction of basic pet info such as age or breed. Or a new name.

• Objective notes from the physical exam. Such as descriptions of a mass or skin condition. Make sure to note the location and size of affected area (if applicable).

• Diagnosis or differential diagnosis given by the veterinarian.

• Services provided such as vaccinations, medications and dosage instructions, diagnostics, and recommendations for the pet parent.

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Conversations with the pet parent do not need to be included unless the veterinarian gives a direct recommendation or the owner reports a concern or symptom.