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.