Suggested Flow

Exam & Pre-Med (Daily Task)

The pre-surgical and wellness exam workflow, including pre-medication.

Clinic HQ makes it to easy to enter exam information in real-time in a paperless system.

In a high volume spay/neuter clinic, the goal of a presurgical exam is to determine if the patient is healthy enough for anesthesia, detect any causes for increased anesthetic risk and ensure they are not already sterilized. Getting the weight and doing the exam should take no more than 2 minutes.

Exam Requirements

Different states require different things on an exam. Furthermore, veterinarians have preferences for what they prefer to be in an exam. High volume spay/neuter clinics and high volume wellness clinics differ from traditional veterinary offices by the sheer amount of patients treated in a day. An exam at a high volume clinic should take two minutes or less. If you do 40 patients, that's still an hour and and twenty minutes for exams. It's important to keep in mind the purpose of the exam: to determine if the animal is healthy enough for anesthesia on that day. Therefore, things like body conditional scores and detailed notes are typically not included in high volume exams, unless required by your state regulations.

Here are the essential seven checkpoints for an exam:

Weight
Sex
Sterilization status
Reproductive cycle
Health (meaning checking for upper respiratory infections, distemper, parvo, skin issues such as mange, wounds, limb issues such as fractures and any other issues)
Abnormalities that include cryptorchidism, umbilical hernias and heart murmurs
Vitals, includes pulse, and respiratory rate and temperature.

For temperature we suggest a Braun ear thermometer
Ear thermometers are a common time and stress-saving practice in many spay/neuter clinics.
Not all clinic take a temperature, some only take a temperature if the animal feels feverish. It should be noted many states REQUIRE a temperature at the moment of exam.
You should check your state vet med regulations to know whether a temperature is or is not required.

Auto-complete exams, HQ for the win

In HQ, all exam findings are automatically marked as normal, as this expedites the examination process, and any abnormalities can be easily changed. In our software, we can also put in a Team Note during the exam, which is then visible to your team. This is a way to give your team a heads up about any issues. Once this is all input into the computer, Clinic HQ will auto-populate the premedication dose amounts on the screen.

Declines & High Risk Waivers

The most common surgical declines are the following: heart murmurs, upper respiratory infections and fevers. You may want to seek high-risk waivers most commonly for over- or underweight patients.

Pre-Meds

Once the weight and the maturity of the patient is put in, pre-medication doses are auto-populated in HQ. The drug drawer (either the veterinarian or a licensed vet tech) will then draw the appropriate premedication drugs into a syringe, place a fresh needle onto the syringe and pass the syringe of premedication off to the veterinarian. The veterinarian will then give the premedication intramuscularly to the canine patient. If your clinic is not entirely paperless, a scribe may mark the time and amounts of which drugs were given on the physical treatment sheet.

The drug drawer will mark the drugs as given and the examination as done, allowing the patient to move over to the next screen for the team to begin pulling up induction drugs.

Dog Identification

The dog is placed in a kennel with a pre-printed cage card. The clear tape for the cage cards is placed on the kennels the night before to avoid messing with tape during the exams. It may seem redundant to have multiple forms of identification for a single patient; however, it is essential to ensure that no patients are mixed up throughout the day. The entire process takes approximately 2 to 3 minutes per patient.

Feline Patients

The flow for feline patients is very similar, with a few key adjustments. The examination, physical treatment sheet and online software remain the same. Cats arrive via curbside drop off, ideally after dog check in is already done, perhaps from noon to 1:00 in order to minimize cat stress. There's no reason for them to wait several hours in the morning while the dogs are being done when your team may not even begin cat surgeries until around noon.

Cats may be kept in their carriers or put in kennels, which should be labeled with masking tape with the cat's first name and the owner's last name as well as a pre-printed cage card. This provides two forms of identification in case one falls off.

The examination follows the essential seven checkpoints already mentioned. Cats may or may not receive a premedication; for example, the ASPCA does use gabapentin as a premed for cats. Cats are placed back in their carriers, or in a kennel, after exam.

Some feline patients may arrive with multiple patients in one carrier. For surgical induction or recovery, it is essential that there is one cat per carrier. Feline patients should be separated during the examination process and clinic-owned carriers should also have a label indicating that they are clinic owned. If cats are not able to be examined, it is acceptable to examine them on the surgical table, but an examination should be done nonetheless. If possible, cats should be placed in a room away from the hustle and bustle of the clinic. Ideally they would be placed on shelves so their vantage point is higher and they will feel safer.

General Flow for Dog Exams & Pre-Meds

Cover scale in newspaper or wipe down with a Rescue wipe
Bring dog into lobby
Take pre-written dog neck collar from packet and put it on dog's neck
Technician puts dog on scale and weighs dog, noting if scale is set to kgs or lbs
Enter weight (making sure HQ is set to kgs or lbs depending on the scale) in Patient Flow
Click drop down for Adult or Pediatric. This designation is can be decided by veterinarian but the reason it's built into the interface here is because many clinics use injectable meloxicam. For inj. meloxicam, the ASPCA Spay/Neuter Alliance's protocols (which many clinics follow) halves the dose of meloxicam (injectable and oral) for dogs 5 months and younger. It should be noted, the medical insert for injectable meloxicam is not suggest for dogs under 5 months and younger. So here it's important to appropriately "age" the pet, since it has implication for drug doses
Note the pre-med dose amounts presented in HQ
The drug drawer (either the veterinarian or a licensed vet tech) will then draw the appropriate premedication drugs into a syringe, place a fresh needle onto the syringe and pass the syringe of premedication off to the veterinarian.
The veterinarian will then give the premedication intramuscularly to the canine patient.
If your clinic is not entirely paperless, a scribe may mark the time and amounts of which drugs were given on the physical treatment sheet.
The drug drawer will mark the drugs as given and the examination as done, allowing the patient to move over to the next screen for the team to begin pulling up induction drugs.

General Flow for Cat Exams

Curbside, label cat carriers with either two masking tapes with the cat's first name and last name. Or a masking tape and the pre-printed cage card.
Cats are brought in from the cars in cat carriers. A clinic owned carrier can be provided to the owner curbside to put in cats that are not in a carrier.
Cats can put put on a high shelving unit until all cats are checked in.
In a room with a closed door, cats can be weighed and examined.
If a cat cannot be handled, an estimated weight can derived.
If a pre-med is being given, it can be given at this point.

Why is my patient not in Patient Flow?

Verify the patient is checked in.
Ensure you are filtering by the correct species in PF.
Change the Anesthetic/Non-Anesthetic dropdown menu to see if they pop up under the Non-Anesthetic patient list. If so, find the patient and click Change to Anesthetic.
For advanced wellness patients that are still not found, check that the wellness appointment type is enabled in Patient Flow under Wellness Settings

Exam Vet

Pre-Surgical Exam: Ensuring Patient Readiness and Safety Before Surgery

The exam veterinarian can be entered from the Exam & Premed tab in Patient Flow.

Purpose of the Pre-Surgical Exam

The purpose of the pre surgical exam is to determine if the patient is healthy enough for anesthesia, detect any causes for increased anesthetic risk, and for spay/neuter surgeries, to ensure they are not already sterilized.

To begin entering an exam, follow these steps:

Once a patient is checked in, they will be pushed over into Patient Flow.
Click the Normal/Abnormal box under the exam column.
Here you can select the exam vet if it's different from the surgical vet.
The default exam can have everything set to normal to speed up this process.
When finished, click the green Done button.

The Essential Checkpoints for an Exam

Weight: Obtain an accurate weight for the patient.
Sex: Verify the sex of the animal, if possible.
Sterilization Status: Check for obvious signs of previous sterilization such as ear-tipping, a tattoo, or a scar is present.
Reproductive Cycle: Is the animal in-heat, lactating, or pregnant?
Health: Check for signs of health ailments such as URI, distemper, parvo, skin issues, etc.
Abnormalities: Check for signs of abnormalities such as cryptorchidism, hernia, or a heart murmur.
Vitals: Record the temperature, pulse, and respiratory rate of the animal.

Not seeing the veterinarian in the exam popup? Make sure the vet is set up in Settings.

Entering Weight, Age, TPR

To begin moving patients through Patient Flow, you will first need to record key information on the Exam & Pre-med tab.

Follow these steps:

Once the animal is weighed, record their official weight in the Kgs or Lbs column. If the weight is estimated, toggle the Weight Estimated switch. If you need to restart, click the Clear button to erase the data.
Record if the patient is pediatric or adult by clicking on the dropdown menu in the Age column. This will be particularly important for age-based medications, like Meloxicam.
To record the patient's TPR, click the Normal button under the Exam column. Enter the exam veterinarian, the vitals, and any findings. Click Done to save.

Note: Once an official weight is set in Patient Flow, you will not be able to edit this from the Checkout page.

Animal Behavior Tags

Behavior tags are an important marker to notify your staff on how to handle patients based on behavior

To access your clinic's tags, click Normal/Abnormal in the Exam column. Select as many tags as necessary, then click Done.

Not seeing behavior tags? Follow this guide to set them up.

Team Notes

If more detailed communication is needed, a team note can also be added from the exam popup or next to the animal's information in Patient Flow. Simply click Team Notes, enter your note, and Save.

Note: Team Notes are private, internal notes used to communicate with other team members. They are not part of the medical record.

SOAP

SOAP notes made quick and easy to help reduce time in front of the computer and focus on the patients in front of you.

S ubjective = Information provided by the patient or owner.

O bjective = Observable and measurable data. A ssessment = The healthcare provider's diagnosis or interpretation of the situation. P lan = The recommended course of action, treatment, or follow-up steps.

Default Normals

The quickest method is to leave all values set to normal and only change them to abnormal if needed. This helps reduce the number of clicks!

If your clinic prefers to not have "normal" pre-selected, you can disable it in Settings > Patient Flow Setup > and untoggle the toggle for "Set exam defaults to 'normal'. If not enabled, the TPR, Subjective and Objective will not be auto-selected to normal."

Short Exam

The standard exam includes the basics when assessing if a patient is a surgical candidate.

It includes the exam vet, TPR, and general SOAP notes.

Short Exam Sections

TPR: Notate whether the TPR is not within normal limits. HQ automatically has these sections set to normal, so you only need to notate if there is an abnormality.
Subjective: Note if the patient passes the BAR test.
Objective: If the exam was not normal or If a full exam could not be completed, you can mark Could Not Exam. The options Loud Purring, Could Not Handle, and Other can be selected.
Assessment: Surgical Candidate: Indicate if the patient is not a surgical candidate.
Plan: Surgically Sterilize: This is where you can decline a patient for surgery before administering meds. To decline, select Decline, then select the No Surgery Reason.

Note: By default, all categories are set to normal to speed up the recording process. If any section is marked abnormal, the system will tag an abnormal exam to notify the team.

This will display in the "Exam" section for your team to view:

The High Risk Waiver

If a high risk waiver is necessary, click Request High Risk Waiver under the standard exam section. This will push the patient to the HRW tab in Patient Flow where you can complete the request. To learn more about high risk waivers, go HERE

Long Exam

Some clinics prefer a more detailed exam...

If that's your clinic, enable the extended exam under Settings > Patient Flow Setup. It will then give you these options.

Example of extended exam

Auto-Triggered Medical Tags With Notes

Medical Notes (Short Tags) are helpful tags that help you quickly note observations.

They are a huge time saver!

Where to Access Medical Tags

This field can be accessed in three main areas:

Exam popup via Patient Flow
Surgery tab via Patient Flow
Treatment Sheet via Checkout

Updating Medical Tags

To update via the exam follow these steps:

Open the exam by going to Patient Flow > Exam & Pre-med. Click the Normal button under Exam.
Scroll past the Extended Exam. This is where Medical Notes (Short Tag) begin.
Update any necessary tags. For example, you can mark if a patient is In Heat, has Fleas/Ticks, and so forth.
Click Done to save.

To update via Patient Flow > Surgery locate the Medical Notes button in the top right corner, next to Surgery Done.

To update via Checkout, go to Check In/Checkout > Treatment Sheet. Find the Medical Notes (Short Tag) field and click Update. Alternatively, you can also update the Exam.

Custom Tags

You can create custom tags for medical notes. They are created under Settings > Custom Fields. In order to be grouped under the Medical Notes (Short Tag) section, the Custom Field Group Is Medical tick box must be checked. Learn more about Custom Fields HERE

Auto-triggered Medical Notes

Each medical tag can be assigned an auto-triggered note to be included in the External Client Communication field. These notes are set up under Settings > Medical Notes. Learn more about setting these up here.

Internal Medical Notes (Manually Written)

The internal medical notes section is a crucial part of the medical record.

All long or written medical notes go here for S/N, Recheck, or Wellness appointments. This section should be used in conjunction with Medical Notes (Short Tags), which are used for quick recording and identification of issues.

Accessing the Internal Medical Notes

This field can be accessed in three main areas:

Exam popup via Patient Flow
Surgery tab via Patient Flow
Treatment Sheet via Checkout

This field can also be reported on later using the Custom Reports tool.

High Risk Waivers

High risk waivers are additional paperwork you have owner's sign that indicates you've shared increased risks with them for their pet. The owner will either accept or decline the risks.

In Clinic HQ, the high-risk waiver is for concerns found during the physical exam on the appointment day and cannot be sent before. An exam must be done before requesting a waiver, as some conditions may only be detected during the exam. Known pre-existing conditions require a manual waiver, and conditions like brachycephalic breeds may be added to the spay/neuter consent form.

HQ automates the process of collecting high-risk waivers via workflows for verbal or email consent. The ASPCA Spay Neuter Alliance uses verbal waivers, and your clinic may choose to follow this model or use a variation with a witness. The following sections will guide you through these workflows.

For instructions on verbal high risk waivers see HERE
For email high risk waiver see HERE

**Our high risk waiver templates can be downloaded HERE

Declining Surgery

Declining Spay/Neuter or Other Procedures

How to decline treatment/surgery from Patient Flow

If an animal showed for their appointment but it was is declined to be treated or receive surgery because of health, aggression, already sterilized - you should indicate this on the Exam.

Anesthetic appointments:

The animal will be on the Exam/Pre-Med click the Exam options Normal / Abnormal to retrieve the exam pop up.
Under the Plan, indicate the animal was declined. This will trigger an additional option to select why the animal is being declined.
Make any additional notes and click Done.
If the animal is scheduled for a spay/neuter appointment, declining will remove the spay/neuter from the list of services.

Non-Anesthetic appointments:

The animal will be on the Roster screen of PF. Click Jump to Finalize. This will redirect you to the Treatment sheet.
Locate the exam box and and in corner, click Update.
Make any additional notes and click Done.

How to decline surgery when the animal has moved past Exam.

Scenario 1: The animal will not be receiving surgery but has been given drugs and/or the animal is on the prep table and discovered to be already sterilized.

At this point the animal should be on the Surgery phase of Patient Flow.
Select the animal from the dropdown menu on Surgery.
Ensure all drugs that were given have been marked as such. Waste any drugs if necessary.
Ensure that the vet's surgery defaults were not applied yet, of so clear the selection.
From the right corner of the Treatment sheet, locate the Action drop down menu beside Paperwork and Medical Notes.
Click Decline Surgery. From the pop up select the reason why.
Remove any services or products from the service list that the animal did not receive.

Scenario 2: The animal was determined already sterilized but only because of an exploratory.

When a spay/neuter appointment is marked for the "Plan: Surgically Sterilize: No," the spay/neuter is removed from services. Most often in this case, you will need to have a line item that is used to charge a client or indicate on the record that the animal went through a surgery. A common line item "Exploratory Surgery" or "Surgery - Already sterilized" works well here.This line item will be applied by staff in lieu of the spay/neuter.

In Patient Flow, here is what you will need to do:

Select the animal from the dropdown menu on Surgery.
Ensure all drugs that were given have been marked as such.
Ensure that the vet's surgery defaults were not applied yet, of so clear the selection. You may need to apply a skin closure technique for females. The Surgery Summary notes box is the ideal place to make notes of what the veterinarian did to determine ABN/ABS. Once those notes are added, be sure to click Save on the Surgery Summary box.
From the right corner of the Treatment sheet, locate the Action drop down menu beside Paperwork and Medical Notes.
Click Decline Surgery. From the pop up select the reason why as Already sterilized.
Additionally when selecting this reason, you will be prompted to indicate how it was determined. In tis scenario, choose Exploratory surgery.
Remove any services or products from the service list that the animal did not receive.

Declining Treatment/Surgery Outside of Patient Flow

If your clinic does not utilize Patient Flow, or you need to note a declined surgery after midnight of the appointment date, you will need to decline from the Exam section of their Treatment Sheet via Checkout.

Navigate to the Checkout page for the appointment by going to Clients > Check In/Checkout > Check In/Checkout and click on the animal's status (In Progress, Checked Out.)
Click on the Treatment Sheet tab.
Click Update on the Exam.
Under the Plan, indicate the animal was declined. This will trigger an additional option to select why the animal is being declined.
Make any additional notes and click Done.
If the animal is scheduled for a spay/neuter appointment, declining will remove the spay/neuter from the list of services.

Drawing & Giving the Pre-Med

Streamlining Pre-Med Flow: Enhancing Efficiency and Patient Care in Your Clinic

Suggested Flow for Pre-medicating:

Dogs

Once the weight and the maturity of the patient are put in, pre-medication doses are auto-populated in HQ. The drug drawer (either the veterinarian or a licensed vet tech) will then draw the appropriate premedication drugs into a syringe, place a fresh needle onto the syringe and pass the syringe of premedication off to the veterinarian. The veterinarian will then give the premedication intramuscularly to the canine patient. If your clinic is not entirely paperless, a scribe may mark the time and amounts of which drugs were given on the physical treatment sheet.

The drug drawer will mark the drugs as given and the examination as done, allowing the patient to move over to the next screen for the team to begin pulling up induction drugs.

Cats

Cats may or may not receive a premedication; for example, the ASPCA does use gabapentin as a premed for cats. Pre-meds can be drawn and logged in HQ the same way if administered.

Kgs vs Lbs

By default, HQ is set up to calculate drug doses based on kilograms (kgs). If your clinic prefers to go by pounds (lbs), you'll need to change this setting in Settings > Clinic Preferences and untick the "Use Kilograms Instead of Pounds" checkbox.

The weight input screen automatically converts kgs to lbs and vice versa.

Auto-generated drug charts

Once the drug protocols are set up in Patient Flow Settings they will auto-generate the dose for each patient. The pre-med can be drawn following this dose.

To note the pre-med in HQ, follow these steps:

Verify the weight and age of the patient are entered.
Click Drugs > Given.
In the popup, note the amount of each drug drawn. Be sure to verify you are pulling from the correct bottle numbers. If there is no textbox under "Amount", you need to open a bottle. Click Open New Bottle.
Click Save.
To push patient to the next tab, click Done.

Tip: Pre-med times given are time stamped in Patient Flow.

Troubleshooting:

"No drugs setup for this animal weight"

Go to Settings > Patient Flow Setup > Drug Charts / Protocol Setup > (select species) Protocol.
Verify your drug has a chart under the Pre-Med Drug Charts section. If not, follow this guide to set it up.
Verify the chart includes the weight of the patient you are attempting to record. You may need to edit or create a new chart if the weight range is missing.
If the chart is there and the weight range is included, check that the chart is enabled. If you see a green "Enable" button, the chart is currently disabled.

Open New Bottle: Add More Bottles

If a drug has no closed bottles available to be opened, you'll need to go back to Settings > Patient Flow Setup and add/manage the controlled bottle inventory. More on that HERE

Kenneling

Dog Identification

The dog is placed in a kennel with a pre-written neck collar and a pre-printed cage card. The clear tape for the cage cards is placed on the kennels the night before to avoid messing with tape during the exams. It may seem redundant to have multiple forms of identification for a single patient; however, it is essential to ensure that no patients are mixed up throughout the day.

The entire process should only take approximately 2 to 3 minutes per patient.

Cat Identification

Cats may be kept in their carriers or put in kennels, which should be labeled with masking tape with the cat’s first name and the owner’s last name as well as a pre-printed cage card. This provides two forms of identification in case one falls off.

Check In

The client and patient check-in process on clinic day.

Patient Flow

Moving patients through surgical and wellness workflows in HQ.