sample of inpatient progress notes (FLUTD)

[CompuMed]

Hi!
Can anyone help here?
I'm medical software engineer doing consulting and freelance work for medical, veterinary and biomedical research communities. My current project is about do develop online inpatient status inquiry system for veterinary practices with the ability for "stay-over" inpatient care. One of my project's demo case is a male feline suffers from acute FLUTD and admitted to the vet hospital with the full urethral blockage for intensive treatment and recovery care. For pet's owners, who would like to monitor their pet current status and progress updates online via secured web-based portal, I developed web module where vet care provider can update the information (progress notes) but for regular customers (pet owners) that should be written in "plain English" and must be enough informative and understandable. Can anyone share with me any FLUTD-related patient progress notes but adapted for reading by non-veterinary / non-medically trained person. I need at least a few notes starting with the severe condition up to improvement.

Any help/responses will be deeply appreciated! Thank you in advance!

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[CookieBear]

I'm no expert, but I'd start with at least just the basics:

Poo, pee, vomit, diarrhea, sneezing, coughing, ate, drank, or any absence of these items. I guess if you want to use only medically appropriate terms you'd probably appear more professional.

Outward appearance (bright, alert, responsive, or active, or lack thereof) - in the case of cats, grooming themselves too, those are additional hallmarks of status/condition.

"Feisty" versus "aggressive" or fractious. Sweet and friendly are always good to hear!

'Blocked' cat? I want to know, did my cat pee yet? Is my cat eating/drinking yet? And the appearance aspect. If I can see that, I pretty much know the 'score'. Straining or not straining to urinate... vocalizing or not... using a litter box or not... but if the cat's blocked, there's no doubt a urinary catheter in, with a closed system, to monitor 'output'. It's not until the cat's peeing, err, passing urine, that the catheter is removed to see how the cat does - and is observed closely. At least, in my experience... Beyond that, perhaps the owner should consider visiting.

In fact, I'd suggest making a comment that suggests to the pet owner that they are welcome and invited to visit. So many animals eat better when their owners come in, their mood improves, etc.

 

[CompuMed]

CookieBear,
Thank you so much for your comments and suggestion. Yes, I'm sure use of medical language would probably appear more professional but this module is not a part of veterinary electronic patient records. This piece is for clients (pet owners) and simple language is more desirable. But if you can give an example of clinical progress notes (using veterinary terms) for such disorder that would also be great! Thanks again for your response!

 

[VelcroSky]

I think that your company is going to need to employ a vet. I don't think it's possible, realistic, or responsible to try and create software that translates medical terminology to layman based on a few posts on the internet.

 

[VelcroSky]

And on further thought, I also don't think it is a good idea because anyone that has any experience in trying to relate to someone how their pet is doing, you know that the same sentence uttered will be heard as many different ways as people that hear it. That's one of the most crucial roles of a vet is to explain to clients how their beloved animal is doing and try to cut through the emotional barriers that distort the conversation. To try and put it on a computer screen that doesn't answer the inevitable questions just isn't responsible, in my opinion.

 

[CompuMed]

...I don't think it's possible, realistic, or responsible to try and create software that translates medical terminology to layman based ....

Software will not translate anything. Software will give ability to enter(capture), store, and finally present the information exactly as human being entered that. The way how human being will express his/her thoughts and translate medical langue into "layman based" it is only up to human being himself. It is only depends on your professional communication ability and skills (doctor-patient or doctor-relatives interaction). You, as medical professional, should be able to explain things in both ways - professional (discussion between your colleagues) and in simple wording (discussion health-related things with no medically-trained / medically-educated people).

. To try and put it on a computer screen that doesn't answer the inevitable questions just isn't responsible, in my opinion.

I respect your opinion but similar idea was successfully implemented and perfectly work in human healthcare industry. There are several hospitals in the US having web-based patient status inquiry systems. They all secured and definitely HIPAA and ePHI complied. Patient's relatives can find out about patient condition in real time via web-based hospital portal. No need for phone calls or physical visits. I personally think it is very useful and helpful. No difference should be in veterinary industry. IMO

 

[docdoc]

It sounds like one more thing that will take a huge amount of my time to write up every day. We already have to do soap notes on hospitalized patients, full H&P on new admits, and write orders to get anything done. The last thing I want to start doing is writing some laymen note daily. Maybe I don't understand what your working on, enlighten me.

 

[CompuMed]

...one more thing that will take a huge amount of my time to write up every day. .

And you shouldn't do it yourself. You have staff of assistants who are in the front of communication with your clients (customers). Updating customers with most current status on their pets condition is usually done by supportive staff so vet doc. shouldn't be bothered with such activity (unless you are alone in your practice and have no staff to assist you with).

If you feel that such thing is not for you - then it is not for you.

I'm not here for collecting thoughts and opinion. I'm here to get your help and assistance (if possible) on what I have asked in my first post. If you can help - great! and I'll apreciate that. If you cannot help - then don't bother yourself and do not waste your valuable time for useless responses.

 

[docdoc]

That's a typical response from someone who has no idea how real world veterinary practice works. Human resources in a veterinary practice are precious. In the human med world "support staff" is everywhere. The amount of money that is wasted on such endevours is sickening. A good "veterinary assistant" that would be qualified to write up notes for family members and owners to read will not have time. They will be taking rads, drawing blood, giving meds and all the other things they are tasked with. The average employee is qualified to clean kennels and walk dogs. I wonder what the MDs would have thought if this perfectly working system required their best nurses to take time away from patient care for more data entry? Veterinary medicine is also much more personal. The best way to keep clients is to speak with them. If they have an animal that is sick enough to warrant hospitalization you better be the forefront of communication.

Toughen up a little Suzy. Sometimes when you come to an internet forum you get thoughts and opinions. If I want to interject some reality I can. Ignore me if it's not what you want to hear. That's the beautiful thing about an open discussion.

 

[CompuMed]

I'm not in a position of deciding needfulness of such "endevours". My job is a software engineering for this project so my role is strictly technical and I would like to stay away from any not concerning my question and request philosophic discussions. Whether or not you would consider using such system that is only up to you. I'm not advertising or trying to sell you anything here. I need help and that is why I'm here. Once again, if you can help with my request that would be great and much more appreciated.