Veterinary Technician NotesDocumentation Guide for CVTs
Complete guide to vet tech documentation including nursing notes, anesthesia records, treatment logs, and lab results. With templates and real-world examples for credentialed veterinary technicians.
The Importance of Vet Tech Documentation
Veterinary technicians are the backbone of patient care in veterinary medicine. Your documentation creates a continuous record of patient monitoring, treatments, and responses that is essential for quality care and legal protection.
Good technician notes capture what the DVM needs to know, when they need to know it. From anesthesia monitoring that documents every 5-minute check to hospitalization notes that track a patient's improvement, your records tell the story of patient care.
AI documentation tools like PatientNotes can help vet techs reduce charting time while maintaining thorough records. Focus on patient care while AI helps with the paperwork.
Vet Tech Documentation Scope
Understanding what you can document independently vs. what requires DVM oversight.
Can Document
- ✓Vital signs (TPR, weight)
- ✓Patient observations and behavior
- ✓Physical assessment findings
- ✓Treatments administered
- ✓Medications given (with DVM order)
- ✓Anesthesia monitoring records
- ✓Laboratory results
- ✓Nursing care provided
- ✓Owner communications
- ✓Post-operative monitoring
- ✓Bandage changes and wound care
- ✓Fluid therapy monitoring
Requires DVM Approval
- ⚠Controlled substance administration
- ⚠Anesthetic drug selection
- ⚠Treatment plan changes
- ⚠Prescription medications
- ⚠Patient discharge
- ⚠Surgical procedures
- ⚠Diagnoses
- ⚠Prognosis statements
Vet Tech Note Templates
Ready-to-use templates for common vet tech documentation tasks.
Admission/Intake Assessment
Initial patient evaluation when admitted to the hospital.
Key Elements:
Example:
VETERINARY TECHNICIAN ADMISSION ASSESSMENT Date: 12/18/2024 | Time: 8:15 AM VT: Amanda Collins, CVT PATIENT INFORMATION: Patient: Buddy Species/Breed: Canine - Beagle Mix Age: 7 years | Sex: MN | Weight: 28.4 lbs Owner: David Park | Phone: (555) 234-5678 Emergency Contact: Same REASON FOR ADMISSION: Scheduled dental prophylaxis with possible extractions HISTORY FROM OWNER: - Last meal: 8 PM last night (fasted per instructions) - Water removed at 6 AM this morning - No vomiting or diarrhea - Normal energy at home - Previous anesthesia: neuter surgery, no complications reported CURRENT MEDICATIONS: - Apoquel 16 mg PO q12h (allergies) - last dose 8 PM yesterday - No other medications ALLERGIES: None known BASELINE VITAL SIGNS: - Temperature: 101.3°F - Heart Rate: 92 bpm, regular rhythm, no murmur ausculted - Respiratory Rate: 18 breaths/min - CRT: <2 seconds - MM: Pink, moist - Hydration: Adequate, skin turgor WNL - BCS: 5/9 PHYSICAL OBSERVATIONS: - Mentation: BAR, friendly, wagging tail - Gait: Ambulatory x4, no lameness - Oral: Grade 3 dental disease visible, foul odor - Abdomen: Soft on palpation, no pain response - Lymph nodes: No enlargement palpated - Ears: Mild erythema AU, no discharge - Eyes: Clear, no discharge STRESS ASSESSMENT: Low - accepting treats, comfortable handling SPECIAL NOTES: - Prefers female handlers per owner - Nervous during blood draws - may need second person - Likes belly rubs to calm down IV CATHETER PLACED: - 22g catheter, right cephalic vein - Time: 8:32 AM - Flushed with heparinized saline, patent - Secured with tape and Vetwrap PRE-ANESTHETIC BLOODWORK: - PCV: 42% | TS: 6.8 g/dL - BUN: 22 | Glucose: 98 - Results within normal limits Patient settled in kennel 12B with water bowl. Ready for DVM pre-op exam. ______________________________ Amanda Collins, CVT
Anesthesia Monitoring Record
Real-time documentation during anesthetic procedures.
Key Elements:
Example:
ANESTHESIA MONITORING RECORD Date: 12/18/2024 Patient: Buddy | Species: Canine | Weight: 28.4 lbs (12.9 kg) Procedure: Dental prophylaxis + extractions Anesthetist: Amanda Collins, CVT Surgeon/DVM: Dr. Sarah Mitchell PRE-ANESTHETIC STATUS: ASA Classification: II (mild dental disease) Pre-op temp: 101.3°F NPO confirmed: Yes (last food 8 PM, water 6 AM) PREMEDICATION (8:45 AM): - Acepromazine 0.02 mg/kg = 0.26 mg IM - Butorphanol 0.2 mg/kg = 2.6 mg IM Patient calm within 10 minutes INDUCTION (9:05 AM): - Propofol 4 mg/kg IV = 52 mg IV to effect - Intubated: 9.0 mm ET tube, cuff inflated - Eyes: Ventromedial rotation, palpebral reflex absent MAINTENANCE: - Isoflurane 1.5-2.5% in O2 (2 L/min) - IV fluids: LRS 5 mL/kg/hr = 65 mL/hr MONITORING LOG: | Time | HR | RR | SpO2 | ETCO2 | BP | Temp | Iso% | Notes | |------|-----|-----|------|-------|-----|------|------|-------| | 9:10 | 85 | 12 | 98 | 42 | 95 | 100.2 | 2.0 | Stable | | 9:15 | 88 | 14 | 99 | 40 | 98 | 100.0 | 2.0 | Dental prophy started | | 9:20 | 82 | 12 | 98 | 44 | 92 | 99.8 | 2.0 | Stable | | 9:25 | 90 | 10 | 97 | 38 | 88 | 99.5 | 1.8 | Extraction 109 | | 9:30 | 95 | 12 | 98 | 40 | 94 | 99.2 | 1.5 | Pain response - deepened | | 9:35 | 85 | 14 | 99 | 42 | 96 | 99.0 | 2.0 | Stable | | 9:40 | 82 | 12 | 98 | 40 | 98 | 98.8 | 2.0 | Extraction 110 | | 9:45 | 88 | 14 | 99 | 38 | 95 | 98.5 | 1.5 | Procedure ending | | 9:50 | 92 | 16 | 99 | 36 | 100 | 98.3 | OFF | Iso off, O2 only | INTRAOPERATIVE NOTES: - 9:28: Slight jaw tone, increased iso to 2.0% - 9:45: Procedure complete, began recovery MEDICATIONS GIVEN DURING PROCEDURE: - Meloxicam 0.2 mg/kg = 2.6 mg SQ (9:40 AM) - Cefazolin 22 mg/kg = 284 mg IV (9:15 AM) FLUIDS: - LRS total: 45 mL/hr x 55 min = ~40 mL RECOVERY (9:50 AM - 10:25 AM): - 9:50: Iso off, spontaneous breathing - 9:55: Swallow reflex present - 10:00: Extubated, lateral recumbency - 10:10: Sternal, responsive to name - 10:25: Standing, ambulatory RECOVERY VITALS: - 10:25: Temp 99.5°F, HR 95, RR 20, MM pink - Patient alert, comfortable Recovery Score: Excellent - smooth, no complications ______________________________ Amanda Collins, CVT
Hospitalization Nursing Notes
Ongoing patient monitoring during hospital stay.
Key Elements:
Example:
HOSPITALIZATION NURSING NOTES Date: 12/18/2024 Patient: Luna | Species: Feline | Diagnosis: Diabetic ketoacidosis DVM: Dr. Jennifer Adams Kennel: ICU 3 --- 7:00 AM - Amanda Collins, CVT --- TPR: T 101.0°F | HR 180 | RR 24 Glucose: 320 mg/dL (target <300) Ketones: Moderate on urine dipstick IV: LRS + 20 mEq KCl at 45 mL/hr - running well CRI: Regular insulin 0.1 U/kg/hr via syringe pump Attitude: QAR, mildly lethargic but responsive Appetite: Offered recovery diet - ate ~1 tbsp Urination: Yes, litter box checked Defecation: No Hydration: Improved from yesterday, skin turgor ~2 sec Notes: Continue current protocol per DVM orders --- 11:00 AM - Amanda Collins, CVT --- TPR: T 100.8°F | HR 168 | RR 22 Glucose: 285 mg/dL (improved!) Ketones: Trace on urine dipstick (decreasing) IV: Running well, changed to new 1L bag at 10:30 Attitude: More alert, purring during exam Appetite: Ate 2 tbsp recovery diet voluntarily Urination: Yes x2 Defecation: Small, soft stool Notes: Glucose trending down nicely. Patient more comfortable. --- 3:00 PM - Jessica Martin, CVT --- TPR: T 101.2°F | HR 160 | RR 20 Glucose: 245 mg/dL (at target!) Ketones: Negative IV: Patent, site clean, no swelling CRI: Reduced to 0.05 U/kg/hr per Dr. Adams Attitude: BAR, grooming self Appetite: Ate full portion offered (1/4 can) Urination: Yes Defecation: Yes, formed Notes: Excellent response to treatment. DVM notified of ketone resolution. --- 7:00 PM - Jessica Martin, CVT --- TPR: T 101.0°F | HR 155 | RR 18 Glucose: 198 mg/dL IV: Fluids decreased to 30 mL/hr per orders CRI: Discontinued, transitioned to SQ insulin - Lantus 1 unit SQ given at 6:30 PM with meal Attitude: Bright, interactive, asking for attention Appetite: Ate dinner (1/2 can prescription DM diet) Urination: Yes Defecation: Normal OVERNIGHT ORDERS (per Dr. Adams): - Continue LRS at 30 mL/hr - Glucose check q4h - If glucose <100, call DVM immediately - If glucose >350, call DVM - Offer food q6h with insulin - AM insulin: 1 unit Lantus SQ with breakfast Patient stable. Plan for discharge tomorrow if glucose remains controlled. ______________________________ Jessica Martin, CVT
Treatment/Procedure Notes
Documentation of specific treatments or procedures performed.
Key Elements:
Example:
TREATMENT NOTES Date: 12/18/2024 | Time: 2:30 PM Patient: Max | Species: Canine - Lab | Dx: Laceration, right forelimb VT: Amanda Collins, CVT DVM: Dr. Sarah Mitchell PROCEDURE: Wound care and bandage change PRE-TREATMENT ASSESSMENT: - Patient BAR, wagging tail - Current bandage: Dry, intact, no strike-through - Pain level: Appears comfortable, no guarding SEDATION (per DVM order): - Butorphanol 0.2 mg/kg = 6 mg IM at 2:35 PM - Patient calm within 10 minutes, lateral recumbency BANDAGE REMOVAL & WOUND ASSESSMENT: - Bandage removed 2:45 PM - Wound appearance: Healthy granulation tissue, no purulent discharge - Wound edges: Approximated, sutures intact (5 of 5 visible) - Surrounding tissue: Mild swelling (improved from yesterday), no erythema - Odor: None WOUND CARE PERFORMED: 1. Flushed with sterile saline (50 mL) 2. Gentle debridement of minimal crusting 3. Applied silver sulfadiazine cream thin layer 4. Non-adherent pad placed over wound 5. Wrapped with cast padding 6. Covered with Vetwrap (blue) 7. Secured with tape strips at top and bottom PATIENT RESPONSE: Tolerated well, no adverse reaction POST-PROCEDURE: - 3:00 PM: Recovered from sedation, sternal - 3:15 PM: Standing, eating treats - E-collar replaced, confirmed fit MEDICATIONS ADMINISTERED: - Cephalexin 500 mg PO (afternoon dose) - Carprofen 50 mg PO with food OWNER COMMUNICATION (phone call 3:30 PM): - Spoke with Mr. Thompson - Updated on wound progress (healing well) - Reminded: E-collar must stay on - Bandage must stay dry - Recheck in 2 days - Owner acknowledged and thanked us DISCHARGE NOTES: If discharging today, include: - Bandage care instructions (written) - Medication schedule - Recheck appointment - E-collar importance ______________________________ Amanda Collins, CVT
Laboratory Results Log
Documentation of lab work performed and results.
Key Elements:
Example:
LABORATORY RESULTS LOG Date: 12/18/2024 Patient: Charlie | Species: Canine - Golden Retriever | Age: 9 years VT: Amanda Collins, CVT DVM: Dr. Sarah Mitchell SAMPLE COLLECTION: - Time: 10:45 AM - Sample types: Venipuncture, jugular vein - 3 mL in purple top, 2 mL in red top - Urine: Cystocentesis - 8 mL obtained COMPLETE BLOOD COUNT (In-house ProCyte): | Parameter | Result | Reference Range | Flag | |-----------|--------|-----------------|------| | WBC | 15.2 | 5.0-14.1 K/uL | HIGH | | RBC | 6.8 | 5.5-8.5 M/uL | | | HGB | 15.2 | 12-18 g/dL | | | HCT | 44% | 37-55% | | | MCV | 65 | 60-74 fL | | | PLT | 285 | 175-500 K/uL | | | Neutrophils | 11.9 | 2.9-12.0 K/uL | | | Lymphocytes | 1.8 | 1.0-4.8 K/uL | | | Monocytes | 1.2 | 0.2-1.4 K/uL | | | Eosinophils | 0.3 | 0.1-1.3 K/uL | | CHEMISTRY PANEL (In-house Catalyst): | Parameter | Result | Reference Range | Flag | |-----------|--------|-----------------|------| | BUN | 42 | 9-29 mg/dL | HIGH | | Creatinine | 2.8 | 0.5-1.5 mg/dL | HIGH | | ALT | 55 | 18-121 U/L | | | ALP | 89 | 5-131 U/L | | | Glucose | 105 | 65-120 mg/dL | | | TP | 6.5 | 5.5-7.5 g/dL | | | Albumin | 3.2 | 2.5-4.0 g/dL | | | Phosphorus | 6.8 | 2.9-6.2 mg/dL | HIGH | URINALYSIS: | Parameter | Result | |-----------|--------| | Collection | Cystocentesis | | Color | Yellow | | Clarity | Clear | | USG | 1.018 (low - expected 1.030+) | | pH | 6.5 | | Protein | 1+ | | Glucose | Negative | | Blood | Trace | | WBC | 0-2/HPF | | RBC | 2-4/HPF | | Bacteria | None seen | | Casts | None seen | | Crystals | None seen | ABNORMAL VALUES SUMMARY: 1. Elevated BUN and Creatinine with low USG - consistent with renal disease 2. Elevated phosphorus - supports renal assessment 3. Mild leukocytosis - monitor DVM NOTIFICATION: - Dr. Mitchell notified at 11:30 AM of renal values - Discussed findings, recommend SDMA and urine culture - Owner to be contacted regarding diagnosis ADDITIONAL TESTING ORDERED: - SDMA (send out to IDEXX) - Urine culture and sensitivity (send out) - Samples submitted 12:00 PM via courier ______________________________ Amanda Collins, CVT
Documentation Best Practices
Tips to make your vet tech notes thorough, accurate, and legally sound.
Be Specific with Times
Always document exact times for medications, treatments, and observations. This is critical for anesthesia records and controlled substances.
Use Objective Language
Document what you observe: "Patient ate 50% of offered food" rather than "Patient had good appetite." Stick to facts.
Document Communications
Note all owner communications including who you spoke with, what was discussed, and any instructions given.
Flag Abnormalities
Clearly highlight concerning findings and document when the DVM was notified. This protects you and ensures follow-up.
Complete Controlled Drug Records
For controlled substances, document: drug name, dose, route, time, patient, who administered, who witnessed.
Initial Your Entries
Always sign or initial your notes with your credentials (CVT, RVT, LVT). This establishes who made the observation.
Frequently Asked Questions
What can veterinary technicians document?
Vet techs can document patient observations, vital signs, treatments administered, anesthetic monitoring, lab results, patient responses, and nursing care. Diagnoses and treatment plans must be documented or approved by the supervising veterinarian.
Do vet tech notes need to be co-signed?
Requirements vary by state and practice. Generally, routine observations and treatments don't require co-signature, but controlled substance administration, anesthetic procedures, and any clinical assessments should be reviewed by the DVM.
What is a TPR and how should it be documented?
TPR stands for Temperature, Pulse, and Respiration - the core vital signs. Document: temperature (°F), heart rate (bpm), respiratory rate (breaths/min), plus weight, hydration status, and any abnormalities noted.
How do you document anesthesia monitoring?
Anesthesia records should include: pre-anesthetic assessment, drugs administered with doses and times, vital signs at 5-minute intervals, depth of anesthesia, any complications, recovery notes, and time to extubation.
What should be included in hospitalization notes?
Hospitalization notes include: TPR checks (typically q4-8 hours), medications administered, appetite/eating, urination/defecation, patient demeanor/comfort level, IV fluid monitoring, wound checks, and any concerns for the DVM.
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