Clinical records

Record vital measurements and medication administration

Link actual measurements, administration and stock results to the correct record.

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Use measurement/administration entries from patient detail or an examination, treatment, inpatient or anesthesia context. This guide records software data; the veterinarian determines clinical values and treatment.

Vital measurement

  1. Open a new vital record for the correct patient.
  2. Compare its timestamp with the actual measurement. Device time and clinic-history timezone can differ; inspect the automatic value.
  3. Fill measured fields; do not enter zero for an unmeasured value.
  4. Save and find the record again by date/patient.
  5. When linking to examination/inpatient/anesthesia, you may choose an existing measurement. Loading or additional pages means an empty search is not conclusive absence.
Field groupUnit and meaning
TemperatureCheck the value with its °C/°F selection
Pulse/respirationNumber and assessment choice are different information
Blood pressureSystolic and diastolic values are separate
SpO2Percentage; blank means unmeasured
Blood glucoseRecord value with the selected unit
WeightCheck value/unit together with weight history
Other findings/notesChoose visible assessments from actual observations

Administer medication

  1. Open Apply Medication and verify patient and actual date.
  2. Choose medication name or product. Product, inventory batch and administration name are different information.
  3. Complete the standard form's route, dosage and unit. This guide supplies no dose recommendation; mg and ml are not equivalent.
  4. For stock deduction, check product, quantity/unit and automatic/manual allocation. Read remaining amount for an offered opened package.
  5. Save and verify administration and stock movement separately. A stock error is not successful completion.

Treatment/anesthesia forms may have different field conditions. Anesthesia has deletion/recreation rather than direct saved-drug editing. If linking to a task failed after creating medication, inspect the existing result before recording a second administration.

Example: today's weight is a measurement; a planned medication task is not administered medication. Verify actual administration and consumed stock through their records. Treatment, units.

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