ABSTRACT
The patient’s record literally tells the story of the patient’s visit, as well as the reason for the visit and the treatment plan. It is the narrative not only of the patient, but also of the caretaker, as told by the doctor and/or technician.
Many things are changing in veterinary medicine, and records are more likely to be digital than paper. This can affect the record, and this chapter examines how those changes can affect the narrative, as well as the significance of the document itself. Records have become more objective and detached, which may not optimize patient care. Human medicine is also attempting to incorporate more “story” into their medical records.
Adding a “C” to SOAP to represent “Client Concerns” is one way to help incorporate narrative medicine into veterinary practice. This chapter gives examples of how to provide context to the medical record, and emphasizes the importance of interpreting information gathered during the physical examination.
