Every vet practice needs a reliable note template. Whether you use SOAP format or a simpler structure, having a consistent template saves time, catches missed details, and keeps your records compliant with Australian veterinary board requirements.
This guide gives you two copy-paste ready templates (SOAP and general), a filled-in example so you can see what good looks like, the most common documentation mistakes, and how to automate the whole process with AI.
What should a vet consult note include?
Australian vet boards require clinical records to be accurate, complete, and retained for a minimum period (typically 3-7 years depending on your state). At a minimum, every consult note should cover:
- Patient identification: Species, breed, age, sex, weight, microchip number
- Owner details: Name and contact information
- Presenting complaint: What the owner says is wrong, in their words
- Relevant history: Medical history, current medications, vaccination status, diet
- Clinical examination: Vitals and physical exam findings
- Diagnostic results: Blood work, imaging, urinalysis — or "none performed"
- Diagnosis: Primary diagnosis or differential list
- Treatment: Medications with drug name, dose, route, frequency, and duration
- Client communication: What you discussed — prognosis, costs, consent, discharge instructions
- Follow-up plan: When to return, what to monitor at home
- Date, time, and veterinarian name
For state-specific record-keeping requirements, check your relevant vet board:
SOAP note template for vets
What is the SOAP format?
SOAP stands for Subjective, Objective, Assessment, Plan. It's the most widely used clinical note structure in veterinary and human medicine because it organises information in a logical, consistent way that's easy to follow on re-read. Each section has a clear purpose:
- Subjective: What the owner tells you — the complaint, history, and context
- Objective: What you find — physical exam, vitals, diagnostics
- Assessment: What you think — diagnosis or differential list
- Plan: What you do — treatment, client instructions, follow-up
SOAP note template (copy-paste ready)
Use this template as a starting point. Adapt the fields to your practice and the type of consult.
SUBJECTIVE
- Presenting complaint: Owner's description of the problem, duration, progression
- History: Relevant medical history, vaccinations, current medications, diet
- Environment: Indoor/outdoor, other animals in household, recent travel or exposure
OBJECTIVE
- Vitals: Temp ___°C | HR ___ bpm | RR ___ brpm | Weight ___ kg | BCS ___/9
- Physical exam: General appearance, cardiovascular, respiratory, abdominal, musculoskeletal, neurological, integumentary, eyes, ears, oral cavity
- Diagnostics: Blood work, imaging, urinalysis results — or "none performed"
ASSESSMENT
- Diagnosis / differentials: Primary diagnosis or ranked differential list
- Prognosis: If relevant to the case
PLAN
- Treatment: Medications with drug name, dose, route, frequency, duration
- Procedures: Anything performed during the consult
- Client instructions: Home care, diet changes, exercise restrictions, warning signs to watch for
- Follow-up: When to return, what to monitor
SOAP note example (filled in)
Here's what a completed SOAP note looks like for a common small animal presentation:
SUBJECTIVE
- Presenting complaint: 4yo MN Labrador Retriever, vomiting x 2 days (3-4 episodes/day), reduced appetite, lethargic since yesterday. Owner reports dog got into kitchen bin 3 days ago.
- History: Vaccinations up to date (C5 due Nov 2026). No current medications. Fed commercial dry food (Royal Canin Medium Adult). No previous GI issues.
- Environment: Indoor/outdoor, one other dog in household (unaffected). No access to toxins. No recent boarding or travel.
OBJECTIVE
- Vitals: Temp 39.1°C | HR 110 bpm | RR 24 brpm | Weight 32 kg | BCS 6/9
- Physical exam: Bright, alert. Estimated 5% dehydrated (tacky MM, mildly prolonged skin tent). Tense on cranial abdominal palpation, no foreign body palpable. No pain on spinal palpation. Remainder of exam unremarkable.
- Diagnostics: In-house biochem — mild ALT elevation (95 U/L, ref 10-80). PCV 45%, TS 72 g/L — normal. Abdominal radiographs: no obstruction, mild gas distension of small intestine. No free fluid.
ASSESSMENT
- Diagnosis: Acute gastroenteritis — likely dietary indiscretion (bin raiding). DDx: pancreatitis (less likely given mild ALT, no severe abdominal pain), partial foreign body (less likely given radiographs).
- Prognosis: Good with supportive care. Monitor for worsening.
PLAN
- Treatment: Maropitant 1 mg/kg SC once today. Metronidazole 15 mg/kg PO BID x 5 days. SC fluids 300 mL LRS administered in clinic.
- Client instructions: Bland diet (boiled chicken breast and white rice) for 3 days, small frequent meals. Ensure access to fresh water. No treats or table scraps. Return immediately if vomiting worsens, bloody stool, or lethargy increases.
- Follow-up: Recheck in 3 days if not improving. Phone check in 24 hours.
General consult note template
General template (copy-paste ready)
Not every practice uses SOAP. This linear template covers the same information in a straightforward format that works well for wellness checks, routine consults, and quick appointments.
- Patient: Species, breed, age, sex, weight, microchip
- Owner: Name, contact
- Date: Date, time, veterinarian
- Reason for visit: Brief description of why the animal was presented
- History: Relevant medical history, current medications, vaccination status
- Examination findings: Vitals, physical exam findings by body system
- Diagnostics: Tests performed and results, or "none performed"
- Diagnosis: Primary diagnosis or differential list
- Treatment: Medications (drug, dose, route, frequency, duration), procedures performed
- Client communication: What was discussed — prognosis, costs, options, consent
- Discharge instructions: Home care, diet, exercise restrictions, warning signs
- Follow-up: When to return, what to monitor
When to use SOAP vs. general format
Both formats capture the same clinical information — the difference is structure. SOAP works best for problem-oriented consults where you're working through a diagnostic process. The general format works well for wellness checks, vaccinations, routine procedures, and quick follow-ups where the SOAP structure feels like overkill. Many practices use both depending on the consult type.
Common mistakes in vet consult notes
These are the documentation gaps that cause the most problems — whether it's a complaint, a malpractice claim, or just a confusing record when the patient comes back six months later.
- Skipping the subjective. Jumping straight to exam findings without documenting what the owner actually told you. If a case goes sideways, the presenting complaint and history are often the most important part of the record.
- Vague treatment plans. Writing "prescribed antibiotics" instead of the drug name, dose, route, frequency, and duration. Every medication should be fully documented — it's a board requirement in most states.
- No follow-up plan. Failing to record when the patient should return or what the owner should monitor at home. This creates liability gaps and makes it harder for the next vet who sees the case.
- Undocumented client communication. You discussed prognosis, treatment options, and costs — but didn't write any of it down. If there's a dispute later, undocumented conversations didn't happen.
- Inconsistent format across vets. Every vet in the practice using a different note structure makes records harder to read, audit, and hand over between shifts. Pick a template and standardise.
- Writing notes hours later. The longer you wait, the less accurate the record. Details get forgotten, mixed up between patients, or simply missed. Notes should be completed as close to the consult as possible.
How to automate vet note-writing
Templates solve the structure problem, but you still have to fill them in — and that's where the real time goes. Most vets spend 5-10 minutes per consult writing notes manually. At 20 consults a day, that's over 2 hours of admin.
AI vet scribes like Whippet Notes eliminate that step entirely. You record your consultation on your phone, and the AI generates complete structured notes — in SOAP or any custom template format your practice uses. The output includes clinical notes, patient summaries, client letters, and billable items.
It also integrates directly with your PMS (Ascend and RxWorks supported), so notes sync straight to the patient record without any copy-pasting.
The result: notes actually get done, they're more thorough than what most vets write manually, and you get that time back for patients, clients, or going home on time.
Try Whippet Notes free for 30 days — no credit card required. Or check out our guide to AI vet scribes to learn more about how it works.
Customising templates for your practice
A single template won't cover every situation. Most practices benefit from having a few variations:
- Species-specific templates: Small animal, equine, and exotic patients have different normal parameters, common presentations, and documentation needs. A template that prompts for BCS makes sense for a dog — less so for a snake.
- Consult-type templates: A detailed SOAP template for sick patients, a shorter format for wellness checks and vaccinations, and a surgical template for procedures.
- Practice-level consistency: Whatever templates you use, make sure every vet in the practice uses the same ones. Consistent notes are easier to read, audit, and hand over between shifts.
With Whippet Notes, you can create custom templates for your practice — set up different formats for different consult types, and every vet's notes come out in the same structure automatically.
