Veterinary Chart Abstraction Form

Reviewer Name: ______Date of Review: ___ / ___ / ____ Data entered: ___ / ___ / ____

Veterinary Hospital: ______Pet ID: ______

Pet Name: ______Owner’s Name: ______

Address: Street: ______City: ______State: _____ Zip: ______

Telephone (Home) ______(Cell)______(Work)______(Other)______

Patient Demographics

Age: ____ □ Years □ MonthsSex: □ Male □ Female □ Neutered/Spayed

Species: □ Dog □ Cat □ Other ______Breed:______

Hair Length: □ Short □ Medium □ Long □ Hairless □ N/ABody Condition Score: ____

Visit Information

Date of Visit: ____ / ____ / ______Time of arrival: ____:____ □ am □ pm

MM DD YYYY

Chief Complaint: ______

Was the patient admitted? □ Y □ N If yes, # Days: ______

Initial Vital Signs: Weight: ______□ kg □ lb

Temp (°F): ______Heart Rate: ______Respiratory Rate: ______O2 sat: ______

Medical History

______

Medications: Heartworm prevention □ Y □ N

______

Decontamination

Was the patient decontaminated? □ Yes □ No □ N/A

If yes, where was the patient decontaminated? How was the patient decontaminated?

□ In the field/At site□ Water

□ At veterinary hospital□ Soap and water

□ Both□ Other: ______

□ Other: ______

Clinical Signs

Check box if the sign is present in the medical record (for this encounter). If date of onset is different from date of presentation, indicate in date column.

Sign Date

General

□ Fever (>103.0 °F)*___ / ___ / ____

□ Hypothermia (<98.0 °F)*___ / ___ / ____

□ Lethargy___ / ___ / ____

□ Other: ______/ ___ / ____

Eye

□ Corneal abrasion___ / ___ / ____

□ Increased tearing___ / ___ / ____

□ Irritation/Pain___ / ___ / ____

□ Itching/Pruritis___ / ___ / ____

□ Miosis___ / ___ / ____

□ Mydriasis___ / ___ / ____

□ Other: ______/ ___ / ____

Cardiovascular

□ Bradycardia*___ / ___ / ____

□ Cardiac arrest___ / ___ / ____

□ Hypertension___ / ___ / ____

□ Hypotension___ / ___ / ____

□ Tachycardia*___ / ___ / ____

□ Other: ______/ ___ / ____

Respiratory

□ Cough___ / ___ / ____

□ Cyanosis___ / ___ / ____

□ Dyspnea___ / ___ / ____

□ Hyperventilation/Tachypnea___ / ___ / ____

□ Nose bleed___ / ___ / ____

□ Phlegm/Congestion___ / ___ / ____

□ Runny nose___ / ___ / ____

□ Stridor___ / ___ / ____

□ Wheezing___ / ___ / ____ □ Other: ______/ ___ / ____

Gastrointestinal

□ Abdominal pain___ / ___ / ____

□ Anorexia___ / ___ / ____

□ Constipation___ / ___ / ____

□ Diarrhea___ / ___ / ____

□ Nausea___ / ___ / ____

□ Vomiting___ / ___ / ____

□ Other: ______/ ___ / ____

Sign Date

Nervous System

□ Ataxia___ / ___ / ____

□ Fasciculations___ / ___ / ____

□ Hyperactive/anxiety/irritable___ / ___ / ____

□ Muscle pain___ / ___ / ____

□ Muscle rigidity___ / ___ / ____

□ Muscle weakness___ / ___ / ____

□ Paralysis___ / ___ / ____

□ Peripheral neuropathy___ / ___ / ____

□ Salivation___ / ___ / ____

□ Other: ______/ ___ / ____

Skin

□ Burns___ / ___ / ____

□ Edema/Swelling___ / ___ / ____

□ Erythema/Redness/Flushing___ / ___ / ____

□ Hives/Welts___ / ___ / ____

□ Irritation/Pain___ / ___ / ____

□ Itching/Pruritis___ / ___ / ____

□ Rash___ / ___ / ____

□ Other: ______/ ___ / ____

*Normal value varies by species

Imaging

Date / Type of Imaging / Location / Contrast / Acute Findings / Description of Acute Findings
___ / ___ / ____ / □ X-ray
□ Ultrasound
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ Ultrasound
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ Ultrasound
□ Other:
______/ □ Y
□ N / □ Y
□ N
___ / ___ / ____ / □ X-ray
□ Ultrasound
□ Other:
______/ □ Y
□ N / □ Y
□ N

EKG

Date / Findings / Description of EKG Findings
___ / ___ / ____ / □ WNL
□ Abnl, consistent
□ Abnl, new
___ / ___ / ____ / □ WNL
□ Abnl, consistent
□ Abnl, new

WNL- within normal limits

Abnl, consistent- Abnormal finding, consistent with medical history or previous disease

Abnl, new- Abnormal finding, may indicate the presence of new disease

Lab Values (See key below for check box explanations)

(Only record actual value if it is initially abnormal or becomes abnormal. Do not record normal values.)

Lab / Repeat Lab Values (if necessary)
Na
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
K
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Cl
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
HCO3-
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
BUN
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Cr
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Glu
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Hgb
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Hct
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
WBC
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Plts
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Ca2+
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
AST
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
ALT
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Total Bili
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
AlkPhos
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Other:
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Other:
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Other:
______/ □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______

Urinalysis

Date: ___ / ___ / ____ / Repeat Lab Values (if necessary)
pH / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Specific Gravity / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Protein / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Glucose / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Ketones / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
WBC / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
RBC / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Bilirubin / □ WNL
□ Abnl, CI
□ Abnl, C Dz
□ Abnl, exposure
□ Abnl, other / Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______
Date: ___ / ___ / ___ Time: ____:____ □ am □ pm ______

WNL- Within normal limits

Abnl, CI- Abnormal, Clinically insignificant (To be determined with NCEH Toxicologists)

Abnl, C Dz- Abnormal finding, consistent with documented chronic disease

Abnl, exposure- Abnormal finding, potentially associated with the exposure

Abnl, other- Clinically significant abnormality, related to other disease process

Arterial Blood Gas (ABG) Flow Sheet

Date / Date / Date / Date
Time / Time / Time / Time
pH / pH / pH / pH
pO2 / pO2 / pO2 / pO2
pCO2 / pCO2 / pCO2 / pCO2
HCO3- / HCO3- / HCO3- / HCO3-
O2 sat / O2 sat / O2 sat / O2 sat
Supplemental O2
□ Y □ N □ N/A / Supplemental O2
□ Y □ N □ N/Ac / Supplemental O2
□ Y □ N □ N/A / Supplemental O2
□ Y □ N □ N/A

Medications (new medications that were initiated or prescribed during this visit/admission)

Name / Indication / Given during this visit? / Continued after discharge?

Outcomes

Diagnosis: ______

Discharge

□ LWBS□ Office visit

□ Admitted: ___ / ___ /____ Discharge information: Date: ___ / ___ /____ Time: ____: _____ □ am □ pm

□ Died: ___ / ___ /____ Cause of death: ______

Necropsy performed? □ Yes □ No □

If yes, where? ______

Necropsy findings: ______

______

□ Other: ______

LWBS- Left without being seen