Page 380 - Clinical Small Animal Internal Medicine

348 Section 5 Critical Care Medicine

Occasionally, emergency interventions are necessary and physical exam, a problem list, a diagnosis list, and
VetBooks.ir at the time of examination to stabilize the patient so that results of laboratory and imaging procedures. For the
duration of hospitalization, a minimum of one physical
further examination and diagnostics can be performed
and an overall treatment plan composed. If it is possible
to complete a comprehensive exam at the time of initial exam should be documented daily as well as an updated
problem/diagnosis list and an updated treatment and
evaluation, it should done. diagnostic plan. The ideal medical record will also docu-
ment communications between the treating veterinarian
and owner and any consulting veterinarians that have
History been involved.

A complete history is required for appropriate care of a
critical patient. During triage and emergency presenta- Client Communication
tion, the need for speed and efficiency often prevents the
gathering of a thorough history. Once the patient’s con- The assessment and medical management of a critical
dition allows, further history to be discovered includes patient are complicated and challenging enough. Adding
past medical problems, past and recent surgical inter- to the difficulty is the need for the clinician to communi-
ventions, origin and travel history, and general wellness cate effectively and compassionately with the owner. As
and preventive care (vaccines, flea/tick/parasite preven- the case evolves, the client needs to be informed of the
tion) schedule. Medications administered by the owner working diagnosis, financial costs, and short‐ and long‐
should be determined, with specific questioning about term prognosis for the current condition. Apprising the
vitamins, supplements, and over‐the‐counter medica- owner of the risks and benefits of each proposed treat-
tions. Efforts should be made to obtain copies of medical ment or therapy is necessary in order for them to make
records from other veterinary facilities where the patient an informed decision. As many of these patients are
has been treated recently and in the past. These records unstable, a CPR resuscitation code is a required topic of
should be carefully reviewed to identify areas in the conversation to ensure that the owner’s wishes are fol-
patient’s history that the owner may have forgotten or lowed in the event of an arrest. Detailed written client
misunderstood. communications should be kept as part of the formal
medical record. These notes help all clinicians involved
with a case to know what has been discussed and when.
Assessment They are also invaluable should a case go to litigation.

After the history and physical exam have been com-
pleted, time should be taken to document the informa- Referral
tion and to form an active problems list. The initial list
may consist of an identified problem without an underly- When treating a critically ill patient, a large considera-
ing cause. Initial therapeutic interventions directed at tion is whether the current facility can offer the patient
the current problem(s) should be initiated and the prob- and client the level of care that they need and want.
lem list and eventual diagnosis list updated as indicated While many facilities may be able to meet the minimum
by response to therapy or results of additional diagnos- standard of care, it is always best to inform the owner of
tics. While a written problem list is commonly used by the option of referral, making sure to communicate the
beginning clinicians and then discarded as clinicians pros and cons of transfer as well as the expected finan-
gain experience, with complicated cases it remains cial cost of treatment at another facility. While some
essential to ensure best patient care. owners may opt to not pursue referral, many will elect
to transfer to a hospital that has 24‐hour doctor care or
other advanced capabilities. For many general practi-
Record Keeping tioners, referral to a 24‐hour facility for any patient
requiring overnight IV fluids or observation is com-
Not only are formal medical records required by law, mon. Cases may also need referral for advanced diag-
they help the clinician keep the case documented and nostics including imaging (ultrasound, computed
organized and assist in transfer between clinicians and tomography, magnetic resonance imaging), advanced
facilities. Medical records also provide information for surgical procedures (soft tissue and orthopedic), or for
follow‐up care after discharge and in the future. The advanced therapeutics (long‐term ventilation, transfu-
medical record should consist of the presenting history sion, dialysis).