Clinical records in VetConnect

Start from the relevant patient tab or application list. Patient-scoped creation fixes the patient; a general list requires patient selection. Phones use section selectors and tablets a sidebar. View, create, update, sign and delete have separate access requirements.

Examination and saving

1. Open Examinations or the patient's examination tab; verify the patient and examination type before creating.
2. Complete Subjective, Objective, Assessment, Plan. Check clinician/date/patient context in the information sheet.
3. Objective/Plan controls open their own measurement, administration, diagnostic, treatment, vaccine and prescription records. Selecting an existing record differs from creating one.
4. Watch autosave status. Wait for pending saves before exit; failures offer retry or an explicit discard decision.
5. Review clinical sections and linked results before signing. Create the current link in Share afterward; do not assume an older link remains valid.

Mobile conflict recovery may merge nonconflicting changes. Inspect local/current choices for fields changed by both editors. Signed or imported examinations remain read-only until explicit Reopen succeeds. Financial summaries require financial access in addition to examination access. Shared examination lifecycle.

Measurements, medication and prescriptions

Check measurement date, displayed unit and patient. For medication, review product, route, dose and selected stock together; dosage is not sale quantity. The anesthesia vital form has different fields from standard patient measurements.

Choose Structured prescription items or Paper scanned documents. A medication-history suggestion fills a draft; it does not administer medication or deduct stock. Structured draft detail holds edits/additions locally until Save. Saved product identities may be locked; distinguish deleting a saved record from removing an unsaved row. Failed saves retain work. PDF and destructive actions are unavailable while dirty; inspect the exit/discard decision. Formats and states.

Vaccines, protocols and programs

1. Open a record from Vaccines, its calendar, Overdue, or the patient tab. Catalog-name and category filters differ; the overdue view does not offer every record-list filter.
2. Choose scheduling date and an exact published protocol/program version. Check species and entry step. The authoring editor validates draft steps/transitions; publishing does not automatically replace a patient's plan.
3. Select an eligible product and stock for administration. Changing catalog clears product/stock; changing product clears stock.
4. If offered, enter a reason to opt out of an automatic next dose. Do not combine this with a manual next date/catalog.
5. Reopen and verify administration, reminders, successor and sale link. Replacing a plan may navigate to its successor; do not administer the older record again.

Some create forms default to the device day; check the clinic day around midnight or time-zone differences. Administration locks clinical edits. Historical protocol attachment does not reopen it. Reminder approval, delivery blocking and sent evidence are separate states. ATS/İTS exports produce files without submitting them to the ministry. Vaccine guide.

Treatment and hospitalization

Use overview, tasks and signature sections in Treatment plan detail. DRAFT → ACTIVE → COMPLETED progression allows reactivation or signing after completion; SIGNED/CANCELLED blocks edits. Check occurrence/series scope and distinguish administration records from task completion. Wait for complete task loading when creating a template.

From the patient's Hospitalizations, select primary clinician, additional care team, room/bed and charge context. Daily input is gross; blank and explicit zero differ. Read day count and total in detail. Discharge uses a clinic date between admission and today. Recheck status, bed and final charge afterward. Treatment, hospitalization, rooms/beds.

Surgery and anesthesia

Lists, patient, Calendar and examination use the same planning flow. Enter patient, type/category, clinic time, duration, lead surgeon, team and preparation. Use the eligible surgery Postpone action rather than generic appointment editing.

Review overview, pre-op, intra-op, post-op and team sections. Required checklists can block starting. Completion and signing are separate. A version conflict refreshes current data without automatically repeating the old action. Anesthesia vital saving blocks exit/duplicate submission; failure returns to the same draft. Surgery, anesthesia.

Test orders and consent

Use Request test in Objective and select laboratory/imaging. Patient/examination context is fixed. Review assignee, priority, execution and sale inclusion; selecting a service alone creates no order. Adding, linking and clinically confirming a result differ. An already-saved warning means find that order before creating another. The mobile diagnostic Device source is currently disabled in normal selection.

Open Consents, choose the appropriate form and patient. For operation consent, select the correct surgery. Your clinician signature is not the owner's signature. Check camera/scan, preview and record state separately. Orders, consent, mobile files/diagnostics.

Synthetic check and recovery

Create a draft examination for test patient Luna and link a measurement and test order. Exit and reopen the same record; compare patient, date/unit, linked records and saved state. Try signature, money and stock effects only in an assigned synthetic environment. After connection loss, read existing records first; repeating creation is not correction.