The animal’s medical record at the vet practice: what it should contain

The patient can’t talk and the owner remembers half of it. “He hurt his leg last year, I can’t remember what you gave him.” In a vet practice the record isn’t an add-on to the examination — it’s the only reliable memory of the animal’s history.

The animal’s identity

• Name, species, breed, sex, date of birth (or estimated age), colour.
• Microchip number and passport number, if there is one — in many countries, Greece among them, microchipping and registration are compulsory for dogs, and the number settles any doubt about identification.
• Neutering status and date.
• Current weight — updated at every visit, since dosages depend on it.
• Allergies and reactions to drugs or anaesthesia, in a prominent place.

The owner — and the household

An owner with two dogs and a cat is one client with three records. The right structure is owner → animals: contact details and balance once, each animal with its own medical record. That way, when they call, you see the whole household — and remember that the second dog is also due a vaccine that month.

Visit history

Every visit in the same order, so any colleague can read it quickly:

1. Reason for the visit in the owner’s words.
2. Clinical examination: temperature, weight, findings.
3. Diagnosis or differential diagnosis.
4. Treatment: drug, dose, duration — not just “antibiotics”.
5. Instructions for the owner and when to come back.

Vaccinations and parasite control

A separate section, not scattered across visits: which product, which date, batch and when the next dose is due. That date is where the reminder to the owner starts — more in the article on vaccination and parasite treatment reminders.

Tests, X-rays and surgery

Haematology, biochemistry, X-rays and ultrasound scans are attached to the record next to the visit that requested them, not in a shared folder on the computer. For surgery, keep the anaesthesia protocol, the surgical note and the owner’s signed consent.

Who sees what

A nurse or assistant needs the schedule and the vaccinations; they don’t necessarily need the owner’s finances. Role-based permissions keep everyone to what they need — and owners’ personal data protected, as GDPR requires.

In VetPro, every animal has a medical record with visits, vaccinations, tests and X-rays, and all the animals in a household are linked to the same owner.

Conclusion

Identity with microchip and allergies at the top, an owner who links the household’s animals, visits with a fixed structure and vaccinations in a section of their own. A record the out-of-hours colleague can read and understand in a minute.