Module 6.5

Question 1

Format of report

Answer 1

Few details in ALL reports, but no standard format
Full signalment
Contact person/info
List of evidence
Summary-history of case
Location(s)-addresses of scene and exam location
Discrepancies
LAYMAN’S TERMS
Abbreviations only after full term used 1st
Timeline
Photos w/w/o annotation
Statement of accuracy/right to amend
Sign and date
Pg # and header/footer

Question 2

Formatting-describing findings

Answer 2

Summary of findings-no opinions
Include normal findings, and detailed abnormal findings-can include full med records w report
Txs and response
Ancillary testing-CBC, Chem, IPS, UA, etc…
Can make table w findings like BCS, PCV, wt., etc.

Question 3

Conclusions

Answer 3

Conclusions-interpret (can include opinions)
Final dx/Ddx, how you came to this, what was ruled out
-explain conditions and effects

Question 4

Remember

Answer 4

Report based on FACTS
Not responsibility of vet staff/animal control to “prove” a case
Vet’s role is to help court understand medical aspects
Be aware of your limitations/forensic limitations
All original documents and photos maintained