About this template
This Veterinary EMR template is designed to help veterinary professionals standardize their physical examination process using the industry-standard SOAP (Subjective, Objective, Assessment, Plan) format. By digitizing your clinical notes, you eliminate the clutter of paper charts and ensure that every patient visit is documented consistently and securely.
This form captures comprehensive patient data, including presenting complaints, vital signs, and detailed system-by-system physical exam findings. It is ideal for busy clinics looking to improve their record-keeping efficiency. Whether you are conducting routine check-ups or managing complex cases, this form provides a structured way to log diagnostics, treatment recommendations, and doctor notes, ensuring all critical health information is organized and easily accessible for follow-up care.
Key features
- Standardized SOAP note structure for consistent clinical documentation.
- Comprehensive system-by-system physical exam checklist.
- Easily log vital signs, diagnostics, and treatment plans.
- Digital signature field for practitioner verification.
- Upload links for lab results, radiographs, or clinical photos.
Use cases
- Routine annual wellness examinations.
- Emergency intake and diagnostic assessment.
- Post-operative follow-up evaluations.
- Specialist consultations and second opinions.
What this form collects
- Date and Time of Exam (Date)Select the date of the current examination.
- Client Information (Short answer)Enter the owner's full name and contact details.
- Patient Details (Paragraph)Include Name, Species, Breed, and Age/Birthdate.
- Presenting Complaint (Paragraph)Briefly describe the primary reason for the visit.
- Subjective History (Paragraph)Note any relevant history provided by the owner.
- Vital Signs (Short answer)Enter Temperature, Pulse, and Respiration (TPR).
- Physical Exam Findings (Paragraph)Note status and any abnormal findings for systems (e.g., Heart, Lungs, Abdomen, Integument).
- Diagnostics & Lab Results (Paragraph)Paste links to external files (Drive/Dropbox) or summarize findings here.
- Assessment & Recommendations (Paragraph)Provide your clinical assessment and treatment plan.
- Attending Veterinarian (Short answer)Name of the doctor performing the exam.
FAQ
Can I customize the system-specific findings?
Yes, once you copy this template to your Google Drive, you can easily add, remove, or rename any of the physical exam sections to match your clinic's specific diagnostic preferences.
How do I handle attachments like X-rays or lab reports?
The form includes a dedicated section where you can paste links to cloud-stored files (such as Google Drive or Dropbox) to keep all diagnostic media linked to the patient's record.
Is this form suitable for telehealth?
Absolutely. This template is perfect for remote consultations, allowing you to collect owner-reported history and subjective observations before or during a virtual visit.
How do I ensure the data is organized?
Every submission is automatically sent to a linked Google Sheet, creating a searchable, chronological database of all patient exams performed at your clinic.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.