Continuity · WET-DOC-06 · STD-06 · In-patient hospital

Medical records and handover of care

Every patient has a digital record: results, recommendations, a record of decisions. Handover between veterinarians and between shifts is structured, so clinical information is not lost “along the way”.

STD-06 · Medical records and handover of care10 steps · SBAR form

Process owner

Medical lead / veterinarian coordinating the in-patient hospital

Participants

Veterinarians, veterinary technicians, hospital staff, reception for administrative data, referring and receiving veterinarians

Purpose

Maintaining full continuity of diagnostics, treatment, nursing supervision and communication with the owner regardless of shift change, the person in charge or the place of care

Scope

All visits, hospitalisations, procedures, examinations, consultations, handovers between shifts, referrals, and handovers of a patient to 24-hour care or to another facility

Location

In-patient hospital

Start

Registration of the patient, admission as an in-patient, or taking over the patient from another veterinarian/shift

End

Discharge of the patient, handover to another provider, or formal assumption of responsibility by the next member of the team

Documents

Digital patient record, hospitalisation record, orders record, anaesthetic record, monitoring record, shift report, discharge sheet, referral, owner's consent

System records

Author and time of the entry, history of changes, results, orders, drugs administered, critical statuses, confirmation that care has been taken over, communication with the owner

Procedure workflow

Procedure STD-06 · CONTINUITY — Medical records and handover of care applies to out-patients, in-patients and peri-operative patients. Its aim is to ensure that complete, up-to-date clinical information and responsibility for the patient are passed on safely between veterinarians, technicians, shifts and facilities.

Good records are accurate, legible, kept up to date, secure and detailed enough for another veterinarian to continue care without reconstructing the history “from memory”. They include, among other things, examinations, results, treatment, the diagnostic plan, the people providing care and the information given to the owner.

Rules that apply

Every patient has a single digital record, which is the source of current clinical information: diagnoses, active problems, results, treatment, recommendations, consents, communication and the plan for further management.

Entries are made immediately after the event or as soon as possible; they must be objective, factual, legible and attributed to a specific author.

Every clinical entry contains at least the date and time, the author, the patient's details, a description of the event, the clinical decision, the actions taken and the further plan.

Information is not deleted in a way that obscures the original entry. A correction requires a new, dated annotation with the author's identifier and the reason for the change.

Handing over a patient means handing over both the information and responsibility for the next steps. The person receiving the patient confirms receipt and understanding of the orders.

A patient without a designated lead veterinarian or a person responsible for the shift is a patient at high organisational risk; the system should not allow such a status.

Important information should be given verbally during the handover and entered in the patient's record. A digital entry alone is not enough for a hospitalised or unstable patient.

Systems for handing cases over between staff are one element of the quality and safety of clinical care.

Structure of the digital records

Patient details

Name, species, breed, sex, reproductive status, date of birth or age, body weight, microchip, identifying features

Owner details

Name, telephone, e-mail, person authorised to make decisions, preferred method of contact

Active problems

Confirmed and working diagnoses, signs, condition after a procedure, risks, allergies, important chronic diseases

Clinical examination

History, vital parameters, examination findings, pain assessment, hydration status, neurological/respiratory/cardiovascular status

Diagnostics

Tests ordered, samples taken, laboratory results, images and reports for X-ray/ultrasound/CT/MRI, consultations, interpretation and decisions

Treatment

Drugs, doses, routes of administration, times, fluid therapy, feeding, oxygen therapy, dressings, procedures, rehabilitation

Hospitalisation

Monitoring parameters, pain assessment, fluid balance, urination, defaecation, appetite, vomiting, position, mobility, nursing care and observations

Procedure and anaesthesia

ASA classification, consent, anaesthetic plan, monitoring record, operative report, implants, samples taken, complications

Plan

Actions to be carried out, person responsible, deadline, condition for escalation, alternative plan, date of the follow-up

Communication

Information given to the owner, time of contact, channel of contact, the owner's decisions, no contact or an unsuccessful attempt to make contact

Discharge / referral

Condition at discharge, diagnosis, treatment given, medications for home, recommendations, warning signs, date of the follow-up, records passed on

Sequence

Creating or verifying the patient record

Confirm the identifier, the owner's details, the microchip and the body weightCheck the alerts: allergies, chronic diseases, infectious status, consentA new record for a new patient, or an update that preserves the history

Recording services as they are provided

Entry made immediately after the action is carried outSOAP structure: Subjective, Objective, Assessment, PlanDrug: name, dose, route, time, person administering, reactionNo entry = order not carried out, to be clarified

Creating a plan for an in-patient

Status: stable / close observation / unstableList of active problems and tasks with a time and a person responsibleUnambiguous orders — no “observe” or “as needed”Integration with STD-02 MONITORING and STD-04 ANALGESIA

Shift handover — SBAR

Before the end of the shift, at the patient's side or with access to the recordSBAR structure: Situation, Background, Assessment, RecommendationThe person taking over asks questions and confirms the prioritiesThe handover is complete once receipt has been confirmed

Content of the SBAR report

S — patient, main problem, urgency, statusB — history, diagnoses, procedure, allergies, drugsA — parameters, pain, wound, hydration, risksR — specific tasks with a deadline and an escalation threshold

Read-back and confirmation of takeover

Repeating the priorities, critical times, doses and thresholdsConfirming that the understanding matches, or correcting itRecording the time, the people involved and the status “handed over and confirmed”Unstable patient — in-person handover at the cage

Change in the patient's condition

Entry and update of the plan at every significant deterioration/improvementUrgent handover: hypoxaemia, hypotension, pain, bleeding, seizuresHandover in the SBAR structure using the repeat-back method

Communication with the owner

Record of every significant conversation: date, time, channel, contentMinimum frequency of updates during hospitalisationFailure to make contact is recorded together with the attemptsSharing data with another facility requires the owner's consent

Referral or external handover

A short clinical summary for the receiving facilityDirect contact for a patient who needs urgent careResponsibility remains until the takeover is confirmedPrompt handover of the records to the veterinarian taking over

Discharge of the patient

Confirm the condition, results, medication plan and pain assessmentDischarge sheet: diagnosis, treatment, recommendations, warning signsWritten or electronic instructions for the ownerNo person responsible or no follow-up date = incomplete discharge

Minimum SBAR handover form

Situation (Situation)Patient identifier, location, stability status, main problem, reason for the handover

Background (Background)Diagnosis, course of the stay, procedures carried out, relevant results, allergies, current drugs, doses given and times

Assessment (Assessment)Current parameters, pain assessment, wound condition, hydration, fluid balance, key abnormalities and trends

Recommendation (Recommendation)Tasks, deadlines, person responsible, alarm thresholds, “if–then” contingency plan, time of reassessment

✓

Confirmation (Confirmation)Names of the person handing over and the person taking over, date/time, read-back, questions and agreed changes

The procedure describes the practice's standard of care; the details of the assessment of a particular patient are decided by the lead veterinarian.

Related services

Where this procedure applies

In-patient hospital · treatment

Hospitalisation with an observation chart

A stay in the practice's in-patient hospital with an individual observation chart: measurements at set intervals, drips delivered by infusion pumps, oxygen, an on-site laboratory and a daily conversation with the owner.

DogCat

In-patient hospital · treatment

Post-operative care and recovery

Supervised recovery in a heated kennel, monitoring of temperature and of pain using a scale, the first feed, and discharge with written instructions. Care from the moment the gas anaesthetic is switched off until the animal is handed back to the owner.

DogCat

Anaesthesia · procedure

General anaesthesia with monitoring

Inhalation or combined anaesthesia carried out according to standard STD-02: intubation, continuous monitoring of vital signs, warming, and a dedicated person watching the patient throughout the procedure.

DogCat

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