These are the observations made by the client. This is often under the chief complaint (CC) The patient history is found here
These are the notes of the veterinarian during the physical examination. This is where vital signs and system review are entered.
This is the diagnosis (Dx), the tentative diagnosis (TDx), or the differential diagnosis (DDx)
This is the plan for additional diagnostic tests, treatment, and procedures. Follow-up appointment and prescriptions are also found here. Dated daily progress notes are here with enties concerning nursing care.