Document a visit
The encounter brings clinical documentation, orders, charges, and closeout together around the appointment.
Open the visit from Schedule after the patient has been checked in.
1. Review the patient
Confirm alerts, active problems, medications, vaccine history, recent labs, and the reason for the visit before documenting.
2. Record the encounter
Veterinarians, technicians, and admins can record vitals and permitted structured clinical work. Veterinarians or admins create and finalize SOAP notes. Record vaccines, prescriptions, manual lab results, procedures, and attachments in their structured areas so they remain searchable and reportable.
Record measurements, vaccines, prescriptions, labs, procedures, and attachments.
Resolve the SOAP record, diagnosis, instructions, warning signs, and follow-up.
3. Finalize clinical closeout
Resolve any SOAP draft, confirm diagnosis and discharge instructions, document warning signs and follow-up, then finalize the clinical portion of the visit.
Finalized clinical records use amendments instead of silent overwrites. Follow the replacement or amendment workflow when a correction is needed.