Patient Assessment, Intervention, and Documentation for the Veterinary Technician
Jody Rockett, DVM; Cynthia Lattanzio AS, BA, JD; Katie Anderson, BS, CVT

VSPN Review by David Liss, BA, RVT Star
(Click on stars for an explanation)

After reading Patient Assessment, Intervention, and Documentation of the Veterinary Technician on a plane ride to a recent veterinary conference, I realized I had a daunting task ahead in writing this review. I went into this read enthusiastic about a book that claims to "address a perceived void in textbooks for the education of veterinary technicians." That void is the lack of a standard notation system for technicians to document nursing concerns, observations, and interventions taken on the patient’s behalf. This little spiral bound book made me, as a seasoned veterinary technician, take a step back and realize how informal our training can be at times, and where I, too, lack formality and education.

This text is designed to teach technicians a standardized system of notation for use in clinical practice. To its success, it does just that. Focusing on the SOAP (Subjective, Objective, Assessment, and Plan) method of notation typically reserved for veterinarians, Patient Assessment, Intervention, and Documentation for the Veterinary Technician has developed a parallel use for veterinary nurses. By focusing on documentation, this book bridges a gap between veterinary nurses and their highly trained counterparts in human medicine. As the supervisor of an intensive care unit, a former student, and the host of many a veterinary technician student, I have found that stressing the importance of documentation often falls on my shoulders. I teach my staff and students to constantly document their actions or observations not only for internal use, but also for legal and ethical standards. Even though the technician schools near my location are exceptional, it appears the authors were correct regarding a lack of formal education in veterinary nurse notation.

The book begins with an overview of the veterinary technician practice model. It establishes a four-step system for identification of a problem and resolution of it. After covering that, it explains the SOAP format for documentation, giving careful examples of how to create patient assessments and not slip into diagnosis (a task for the veterinarian). After identifying the format of a Medical Administration/Order Record, or MAOR, the book delves into many examples to familiarize its readers with the new style of notation. In the Generating the Database section, technician nomenclature and basic principles such as physical exams and diagnostic testing are discussed to build the technician’s knowledge base for properly identifying abnormalities and intervening appropriately. The next section describes the system of evaluations a technician may make when presented with a case, and the respective suggested interventions. Examples include: aggression, client knowledge deficit, client coping deficit, and exercise intolerance. These are not diagnoses but rather important key elements of patient wellbeing. The book then moves on to medical and surgical conditions. These sections help technicians learn the evaluations associated with various disease processes, and familiarize them with implementing these evaluations in clinical practice. The last section discusses therapeutic procedures associated with technician evaluations and interventions.

I appreciated this book for many reasons. It solidly created a reproducible, informative, accessible, learnable, and easily implemented system of notation that veterinary technicians of varying levels and experience could utilize. The book not only solidifies the importance of technical skills, but also considers technicians’ observations and suggestions for action to be absolutely essential. The plethora of examples given also makes it very useful for those already faced with a system or hospital policy for documentation. Teaching this system to students or employees will be made much easier by using the examples.

I found the book lacking in several areas. It was not creatively designed, and every page has the same setup and same font style. It became very tedious after 200-odd pages of the same format. With absolutely no visual aids other than a few chapter headings, the book began to lose context as the words on the page ran together. Also, I found it lacking in its medical complexity. At times it seemed to be too simple, and I was unsure if this was meant for a beginning technician student, seasoned technician, or even technician specialist, although I believe everyone in the profession would benefit from it. I found myself writing in additional symptoms, or interventions I would have performed in my clinical duties.

I am conflicted in my review of Patient Assessment, Intervention, and Documentation for the Veterinary Technician. On the one hand, I enjoyed learning a new system that I think will be valuable in teaching future generations of veterinary technician students. On the other hand, I struggle with its application in clinical practice. Working in a busy ICU, I rarely find time to write my assessments and interventions in the format as suggested by the authors. This book seemed to be more geared towards a general practice technician, who I also feel rarely has time to write the extensive notes suggested by this book. It is essential to document what you noticed, and what happened, but identifying the steps leading to an intervention is often based on experience. This text is ideal for students as a learning tool to craft their future career. In a clinical setting, and for veterinarians, it provides a great adjunct to an already established system of notation. It would also be perfect to implement as the standard of notation at a new facility. Bringing it in to an already up and running facility would definitely increase the standard of care, and would be highly recommended, but might be difficult and time consuming.

I enjoyed the book and found the new system intriguing, useful, and intelligent. I believe we should all move in this direction as technicians, and would like to see the book utilized in veterinary technician curricula. However, a clinical quick reference it is not.

Publisher: Delmar, Cengage Learning (2009);

348 pages, soft cover.

ISBN-13: 978-1-4180-6749-6

ISBN-10: 1-4180-6749-0.

Table of Contents
Book Reviews
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Alternative Medicine
Animal Welfare
Client Education
Cytology / Hematology / Histology
Emergency Med
Food Animals/Livestock
Handling & Restraint
Human-Animal Bond
Imaging & Radiology
Infectious Diseases
Internal Medicine
Laboratory Medicine
Practice Management
Rabbits, Rodents & Ferrets
Shelter Medicine
* Animal Bio. & Care 2nd Ed.
* Appl. Pharm. Tech. 4th Ed. (VSPN Review)
* BSAVA Nursing 4th Ed.
* Career Choice (VSPN Review)
* Common Disease 2nd Ed. (VSPN Review)
* Lab. Vet. Tech. 5th Ed. (VSPN Review)
* Large Animal Vet. Tech. (VSPN Review)
* Mosby PDQ (VSPN Review)
* Radiography Tech. 4th Ed. (VSPN Review)
* Rev. Q&A Tech. 3rd Ed. (VSPN Review)
* Small Animal Toxicology, 2nd Ed.
* Textbook Of Veterinary Physiological Chemistry: 2nd ed
* Vet. Dentistry Tech. (VSPN Review)
* Vet. Nursing Exotic
* VSPN Notebook 3.0 (VSPN Review)
* Workbook McCurnin 7th Ed. (VSPN Review)
A Veterinary Technicians Guide to Exotic Animal Care, 2nd Edition (VSPN)
AAEVT Equine Vet. Tech.
AAEVT’S Equine Manual for Veterinary Technicians (VSPN Review)
Abdominal Radiology for the Small Animal Practitioner
Advanced Monitoring and Procedures for Small Animal Emergency and Critical Care
All Horse Systems Go (VSPN Review)
An Illustrated Guide to Veterinary Medical Terminology, 4th Ed (VSPN)
Anaesthesia Nurses 2nd Ed.
Anaesthesia Nurses 2nd Ed. (VSPN Review)
Anatomy and Physiology for Veterinary Technicians and Nurse: A Clini Appr (VSPN Review)
Anesthesia for Veterinary Technicians
Anesthesia for Veterinary Technicians (VSPN Review)
Anthology of Biosafety XII: Managing Challenges for Safe Operations of BSL-3/ABSL-3 Facilities
Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Dermatology, 2nd Ed
Blackwell’s Five-Minute Veterinary Consult Clinical Companion: Small Animal Dermatology, 2nd Ed
Boothe’s Small Animal Formulary 7th Ed (VSPN)
BSAVA Can. Fel. Nursing 2nd Ed.
BSAVA Manual of Canine and Feline Cardiorespiratory Medicine, 2nd Ed. (VSPN Review)
BSAVA Textbook of Veterinary Nursing, 5th ed (VSPN)
Calculations Vet. Nurses
Cardiovascular Disease in Small Animal Medicine, 3rd Ed.
Clin. Anat. Lab. Tech. (VSPN Review)
Clin. Anat. Tech. 2nd Ed. (VSPN Review)
Clinical Laboratory Animal Medicine: An Introduction, 4th Ed (VSPN)
Clinical Pathology & Laboratory Techniques for Veterinary Technicians (VSPN)
Clinical Veterinary Advisor: Dogs and Cats, 2nd Ed
Companion Animals in Society (VSPN)
Comparative Veterinary Histology
COMPAS Material Safety Data Systems
Dermatology for the Small Animal Practitioner (VSPN Review)
Diagnostic Imaging of Exotic Pets: Birds, Small Mammals, Reptiles
Digital Radiography for the Veterinary Technician, 1st Ed. (VSPN Review)
Dorland’s Illustrated Medical Dictionary 32nd Ed. ( VSPN)
Endoscopy for the Veterinary Technician
Equine Nursing Manual
Essentials of Veterinary Parasitology
Ethnoveterinary Botanical Medicine, Herbal Medicines for Animal Health (VSPN)
Exotic Animal Medicine for the Vet Tech, 2nd Ed (VSPN Review)
Fluid Therapy for Veterinary Technicians and Nurses (VSPM)
Focused Ultrasound Techniques for the Small Animal Practitioner (VSPN)
Fundamentals of Pharmacology for Veterinary Technicians, 2nd Edition
Fundamentals of Small Animal Surgery 1st ed
Handbook Radio. Positioning (VSPN Review)
Hematology Techniques & Concepts for Veterinary Technicians, 2nd Ed
Hematology Techniques and Concepts for Veterinary Technicians, 2nd Ed.
How We Do Things Here: Developing and Teaching Office-Wide Protocols (VSPN)
Inspecting Surgical Instruments – An Illustrated Guide (VSPN Review)
Introduction to Veterinary Anatomy and Physiology, 2nd Ed
Kirk And Bistner’s Handbook Of Veterinary Procedures And Emergency Treatment, 9th Ed.
Large Animal Clinical Procedures for Veterinary Technicians, 2nd Ed
Manual Clin. Dog Cat 3rd Ed.
McCurnin Tech. 7th Ed.
McCurnin’s Clinical Textbook for Veterinary Technicians, 8 Ed (VSPN)
Merck Veterinary Manual, 10th Ed
Mosby Tech. 3rd Ed. (VSPN Review)
North American Companion Animal Formulary, 10th Edition (VSPN)
Nutrition and Disease Management for Veterinary Technicians, 2nd Ed
Nutrition Vet. Tech.
Otitis Externa: An Essential Guide to Diagnosis and Treatment (VSPN)
Pain Management for Veterinary Technicians and Nurses
Pain Management for Veterinary Technicians and Nurses( VSPN)
You are herePatient Assessment (VSPN Review)
Plumb’s Veterinary Drug Handbook, 7th Ed (VSPN Review)
Pocket Guide to APA Style, 4th Ed
Pocket Handbook of Nonhuman Primate Clinical Medicine (VSPN)
Practical Imaging Tech. 3rd Ed. (VSPN Review)
Principles and Practices of Veterinary Technology, 3rd Ed (VSPN Review)
Purchasing Digital Radiography Without Getting Your Head Handed To You
Rabbit Med. Surg. Nurse
Radiation Safety and Non-Manual Patient Restraint in Veterinary Radiography
Restraint and Handling for Veterinary Technicians (VSPN Review)
Review Q&A for Vet Techs, 4th Ed. (VSPN Review)
SA Emergency Tech. 2nd Ed. (VSPN Review)
Saunders Handbook of Veterinary Drugs, Small and Large Animals, 4th Ed
Small Animal Diagnostic Ultrasound, 2nd Ed. ( VSPN)
Small Animal Toxicology Essentials, 2nd Ed
Standard Abbreviations for Veterinary Medical Records, 3rd Ed. (VSPN)
Statistics at the Bench
Surgical Instrument Flash Cards (VSPN Review)
Team Satisfaction Pays - Organizational Development for Practice Success (VSPN)
Tech. Guide Exotic Care
The Consulting Veterinary Nurse
The Feline Patient 4th edition (VSPN Review)
The Little Book of CT in Veterinary Medicine: A PRACTICAL Guide to CT Technique for Technicians and Veterinarians
The VSPN Notebook®, Version 4.0 (VSPN Review)
The Welfare of Animal Used in Research: Practice and Ethics (VSPN)
Thoracic Radiology for the Small Animal Practitioner
Unlocking Medical Terminology (VSPN Review)
Vet. Clinical LA (VSPN Review)
Veterinary Assisting Fundamentals (VSPN Review)
Veterinary Cytology of the Dog, Cat, Horse and Cow
Veterinary Disaster Response
Veterinary Echocardiography, 2nd Ed. (VSPN Review)
Veterinary Hematology – A Diagnostic Guide and Color Atlas (VSPN)
Veterinary Technician’s Daily Reference Guide: Canine and Feline (VSPN)
Veterinary Technician’s Large Animal Daily Reference Guide (VSPN)
Writing the Research Paper – A Handbook, 8th Ed
* Appl. Pharm. Tech. 3rd Ed. (VSPN Review)
* Clinical Tech. 5th Ed.
* Clinical Tech. 6th Ed. (VSPN Review)
* Common Disease (VSPN Review)
* Exotic Med. Vet. Tech.
* Hematology Techniques
* SA Surg. Nursing (VSPN Review)
* Vet. Tech. Pocket (VSPN Review)
*Tasks Vet. Asst. 2nd Ed.
*Tasks Vet. Asst. 2nd Ed. (VSPN Review)
*Vet. Dermatology Nurses
*Vet. Tech. Dog Cat 2nd Ed.
Veterinary Education
Wildlife-Zoo Animals

Date Published: November 17, 2009

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