Clinical Notes

Document consultations with structured SOAP notes, diagnoses, treatment plans, and prescriptions — with optional AI-assisted drafting.

SOAP Note Structure

VetLoop uses the standard veterinary SOAP format:

• S — Subjective: Owner-reported history and chief complaint.
• O — Objective: Clinical examination findings — weight, temperature, heart rate, physical findings.
• A — Assessment: Differential diagnoses and working diagnosis.
• P — Plan: Treatment plan, medications prescribed, follow-up instructions.

Each section is a free-text field with formatting support (bold, lists). Vitals in the Objective section are structured numeric fields so they can appear in trend graphs over time.

Creating a Note

1. Open a patient recordNavigate to the patient and tap the Clinical Notes tab.
2. Tap + New ConsultationChoose the consultation type (routine, emergency, follow-up, dental, etc.) and confirm the attending vet.
3. Fill in each SOAP sectionTab or scroll through Subjective → Objective → Assessment → Plan. Vitals fields are at the top of the Objective section.
4. Add diagnosesIn the Assessment section tap + Add Diagnosis. Search by condition name or ICD-10 code.
5. Add prescriptionsIn the Plan section tap + Prescribe. This pulls from your inventory; stock is deducted when the prescription is dispensed.
6. Save & SignTap Sign Note to finalise. Signed notes are locked from editing (an amendment process is available if needed). Unsigned drafts auto-save.

Diagnoses & Problems

Tap + Add Diagnosis in the Assessment field to link a coded diagnosis to the note. VetLoop uses a combined VeNom and free-text coding system. Each patient maintains an active Problem List — mark a diagnosis as Active Problem to add it to the list and have it appear as an alert in future consults.

Treatment Plans

In the Plan section, tap + Add Treatment Item to build a structured treatment plan with:

• Procedure or medication name (links to inventory for costing).
• Dosage / instructions.
• Frequency and duration.
• Responsible staff member.

Treatment plan items can be bulk-converted to invoice line items at any point during or after the consult, saving double-entry.

Prescriptions

Tap + Prescribe to issue a prescription. Select a medication from inventory, enter dose, frequency, and duration. VetLoop generates a prescription label with practice details, patient and owner name, dosing instructions, and refill status. Schedule 5/6/7 substances require a DEA registration number to be configured in Settings.

A Repeat Prescription records the number of authorized repeats. Each refill is logged and visible on the patient's Prescriptions tab.

Viewing Note History

All signed notes appear in reverse-chronological order under the patient's Clinical Notes tab. You can filter by date range, vet, or diagnosis. Tap any note to view it in read-only mode. Use the Compare button to view two notes side-by-side — useful for tracking progress on chronic conditions.

Deleted notes are never truly removed — they are archived and visible to administrators in the audit log.

Note Templates

Create reusable templates for common consultation types (e.g. annual wellness exam, spay/neuter, dental scale) under Settings → Clinical Templates. Templates pre-fill the SOAP structure, letting you edit only what changed. Templates can include default diagnoses and treatment plans.