POVMR & SOAP Record Formats in Veterinary Medicine

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  • 0:00 The POVMR
  • 0:35 Database, Problem…
  • 2:48 SOAP
  • 4:35 Lesson Summary
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Lesson Transcript
Instructor: Artem Cheprasov

Artem has a doctor of veterinary medicine degree.

This lesson will define the POVMR (problem-oriented veterinary medical record) and its four sections, as well as a brief example of the SOAP format used in the POVMR.

The POVMR

People come to a veterinary hospital when their pet has a problem. And so, it's only fair that when a medical record is established, it's a special kind of medical record called a POVMR, or a problem-oriented veterinary medical record. The POVMR, compared to older principles used in veterinary medicine, focuses on a scientific process more so than anything else in order to diagnose and properly treat a patient.

Most veterinary hospitals, including those that are accredited by AAHA, the American Animal Hospital Association, follow this formation for medical records. This record has four sections, which we will discuss.

Database, Problem List, Initial Plan

Let's pretend that a dog comes in to the clinic. The dog's name is Barky, and Barky's owner's name is Joan. Let's say that Barky has come in with a limp and a swelling in one of the rear legs that is painful to the touch. The POVMR will help a veterinarian figure out what could be wrong with Barky.

One phase of the POVMR is known as the database. Here, the patient's history, physical exam data, and any laboratory results are compiled. The database should be as complete as possible and organized. For instance, the data in the database might be grouped according to which organ systems are normal and which are not.

Another phase is known as the problem list. It's a numbered list of all of the problems found during the compilation of the database. What is a problem in the medical sense? A problem is anything that requires, might require, or has required medical or surgical intervention.

In our case, a big problem is that the physical exam noted a limp, a swelling on the leg, and pain upon palpation, the examination of a body part or area by touch. Those things are obviously part of the problem list, and they may sometimes be combined into one overarching problem as the veterinarian sees fit.

The next phase of the POVMR is the plan or plan formulation. Here we answer: what do we do next? Plans include diagnostic plans, therapeutic plans, and client education plans. In Barky's case, part of the veterinarian's initial plan is the diagnostic plan, and it includes getting an x-ray of the leg to look for signs of a fracture or something stuck in the leg that may be causing the swelling, limp, and pain.

Once a diagnosis is reached - in Poor Barky's case, it's a broken bone - a therapeutic plan can be drawn up. This may include the different options for fixing the bone, as well as any rehabilitation that may be necessary after surgery.

After figuring out the therapeutic plan, the client education plan can be made. The client education plan can outline things like the risks involved with any planned therapy and the prognosis for recovery.

SOAP

The fourth part of the POVMR is called progress notes, or simply follow-up notes/plans. The progress notes must use the SOAP format, which stands for subjective, objective, assessment, & plan.

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