Medical record example

AI-Generated Veterinary Call Summary

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Example Medical Record

Call Summary

Bella

Thursday, July 30, 2026 at 5:15 PM

Call Summary

Discussed Bella’s recent test results, current treatment progress, and next steps for her ongoing care. The call lasted approximately 12 minutes and included updates on bloodwork, medication adjustments, and follow-up scheduling.

Tests

  • Blood Panel: Mild elevation in liver enzymes (ALT slightly above normal range)
  • Urinalysis: Normal, no signs of infection or crystalluria
  • Fecal Exam: Negative for parasites
  • X-Rays (from July 28): No foreign objects; mild arthritis noted in hips

Treatment

  • Continued prescription diet (Hill’s i/d) for gastrointestinal support
  • Added joint supplement (Dasuquin) to help manage early arthritis signs
  • Discontinued previous probiotic due to GI stabilization

Monitoring

  • Watch for vomiting, diarrhea, or decreased appetite
  • Note any changes in mobility or signs of discomfort, especially after exercise
  • Monitor water intake and urination frequency

Medications

  • Carprofen (25 mg): ½ tablet twice daily with food, for inflammation/pain
  • Maropitant (Cerenia): 16 mg once daily for 5 days, if nausea recurs
  • Dasuquin Chews: 1 chew daily with food

Follow-Up

  • Recheck liver values in 3–4 weeks (tentatively scheduled for August 27)
  • Call clinic sooner if GI symptoms return or Bella becomes lethargic
  • Consider follow-up x-rays in 6 months to reassess hips
Generated by PawfectNotes

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Why vets choose PawfectNotes for Call Summaries

  • Auto-generates in seconds
  • Accurate clinical terminology
  • Customizable templates
  • Voice dictation + real-time editing

Frequently Asked Questions

  • Are these templates customizable?Yes. Set your default template, choose your specialty and your own normal findings for the SOAP note, or duplicate a built-in template and change it to match your EMR format.
  • Can I add my own note types?Yes — build your own template in Templates (sections, fields, formats) and share it with your practice. See how customization works.

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