Communication & Veterinary Professional Support Services Free guide

Medical Records, SOAP Notes and the VCPR for Veterinary Technicians

Communication & Veterinary Professional Support Services (D10 B, C; D1 D, E; K48) 13 min read, 2,838 words Last verified

What goes in each part of a SOAP note, how to correct a record, when you may release it, how long to keep it, and what makes a valid VCPR.

Introduction

The medical record is the written story of a patient's care. It is how the next person on shift knows what was done, how a referral hospital learns the history, and how a state board decides whether care met the standard. Veterinary technicians write much of it: the history, the vital signs, the treatments given, the client phone calls and the discharge notes.

This guide covers what a record must contain, the problem-oriented record and the SOAP note, safe abbreviations, how to correct an error, confidentiality and release, retention periods, and the veterinarian-client-patient relationship (VCPR). The VCPR matters to you because it decides whether the practice may legally dispense or prescribe a drug for a patient.

Key facts

  • SOAP stands for Subjective, Objective, Assessment and Plan. Subjective is the history and complaint from the owner; Objective is measurable data such as temperature, pulse, respiration, weight and exam findings.8
  • Medical records are the property of the practice and the practice owner. The information in them is confidential and is released only as required or allowed by law, or with client consent.1
  • A paper charting error is corrected with a single line through it plus your initials. Never erase it, scribble it out or cover it with correction fluid.9
  • Every entry should carry the date and the identity of the person who wrote it.579
  • Retention is set by each state. Pennsylvania and Texas require at least 3 years after the last visit or treatment; New Jersey requires 5 years from the last visit for a living patient.567
  • Under federal law a valid VCPR needs three things: the veterinarian has taken responsibility and the client agrees to follow instructions, the veterinarian knows the animal well enough for at least a preliminary diagnosis, and the veterinarian is available for follow-up.3
  • A veterinarian may legally use or dispense a prescription animal drug only within a valid VCPR, and practice employees may not sell prescription drugs to walk-in customers who lack one.4

How the VTNE tests this

  • Sort findings into SOAP sections. You may be given an owner statement, a temperature and a drug order and asked where each belongs. Record keeping is Knowledge statement 48 of the 2023 outline.11
  • Collect patient information. Domain 10 Task C covers signalment, medical history and primary complaint, which make up the Subjective part of the note.11
  • Choose the correct action. Scenarios about fixing a charting error, answering a records request from a third party or sharing a login test professional conduct under Domain 10 Task B.11
  • Link records to drugs. Domain 1 Task E asks you to maintain controlled drug logbooks and medical records, and Task D to dispense in compliance with veterinary orders, which depends on a VCPR.11

Core concepts

Why the record exists

Pennsylvania's veterinary rule sums up the purpose well: the record is the basis for planning care, a means of communication within the practice, and documentary evidence of the illness and the treatment given. It must be written so that any veterinarian reading it could carry on with the patient's care.5 In court and in board reviews the working rule is "if it wasn't documented, it wasn't done."9

What a record must contain

Each state lists its own minimum contents, but the lists overlap heavily. Texas, for example, requires the owner's name, address and phone number; the species and identity of the animal; age, sex, color and breed; dates of exam and treatment; a brief history; weight, temperature, pulse and respiration where needed; lab and imaging results; the differential diagnosis; treatments and results; every drug with its dose; surgical details including the anesthetic agent, route and dose; and anesthesia monitoring.6 Pennsylvania adds the vaccination history and requires the record to document communication with the client, including consent to, or refusal of, recommended tests and treatments.5 Records on livestock or litters may be kept per client rather than per animal in Texas.6

Signalment is the short description of the patient: species, breed, age, sex and reproductive status, for example "2 y/o, K9, MN, miniature poodle".8

Source-oriented and problem-oriented records

A source-oriented record files information by where it came from: all lab reports together, all imaging together, all progress notes together. A problem-oriented medical record (POMR) instead organizes care around each of the patient's problems. The POMR was proposed by Weed in 1968 and is used together with the SOAP format.13 Pennsylvania requires records to be kept "in a problem-oriented or similar format."5 In a POMR, each problem on the problem list gets its own SOAP entry, so a dog with ear disease and obesity has two separate assessments and plans.

The SOAP note

The SOAP note is the most common format for writing up an appointment or a daily progress entry.8 The split between Subjective and Objective is the part students most often get wrong. Subjective means information that cannot be measured, mostly what the owner tells you. Objective means anything you measured or observed on the exam or in a test.8 The Assessment interprets the S and O data, with the diagnosis or list of differential diagnoses, and the Plan lists the next diagnostic or treatment steps.8 The technician usually writes S and O and records the plan as ordered. The Assessment is the veterinarian's medical judgment.

Table 1. The four parts of a SOAP note, with a sample entry for a fictional patient
SectionWhat goes hereExample entry ("Biscuit", 6 y/o K9 FS Labrador)
S: SubjectivePresenting complaint and history from the owner; non-measurable informationOwner reports vomiting 3 times since yesterday evening; ate a corn cob at a barbecue 2 days ago; still drinking.
O: ObjectiveMeasurable findings: T, P, R, weight, CRT, mucous membranes, body condition score, exam and test resultsT 102.8°F, HR 120 bpm, RR 28 brpm, wt 31.2 kg, MM pink, CRT under 2 s, painful on cranial abdominal palpation.
A: AssessmentThe veterinarian's evaluation: diagnosis or differential diagnoses, and severityDDx: gastrointestinal foreign body, dietary indiscretion, pancreatitis.
P: PlanNext diagnostic and treatment steps, client communicationAbdominal radiographs; IV fluids; owner informed of estimate and consents to radiographs.

Source: section definitions from Introduction to Veterinary Terminology, section 6.38; example entry is an original illustration.

Annotated SOAP note for a fictional dog, with the source of each section labelled Progress note: "Biscuit" Smith 6 y/o, K9, FS, Labrador retriever 03/14/2026 10:15, entry by J. Lee, CVT S Owner reports vomiting x3 since last night. Ate corn cob 2 days ago. Drinking normally. O T 102.8°F HR 120 RR 28 Wt 31.2 kg MM pink CRT <2 s Painful cranial abdomen. Wt 3.12 kg mistaken entry JL 03/14/26 A DDx: GI foreign body, dietary indiscretion, pancreatitis. (veterinarian's assessment) P Abdominal radiographs. IV fluids per DVM order. Estimate given; owner consents to radiographs. Signed: J. Lee, CVT No blank lines left between entries. Signalment, date, time and who wrote the entry Owner's words: history and complaint (not measured) Measured or observed: vitals, weight, exam findings Error: single line, still readable, initialed Interpretation and differential diagnoses Tests, treatments, client consent or refusal
Figure 1. An annotated SOAP note for a fictional patient. S holds what the owner reports, O holds what you measured, A is the veterinarian's interpretation and P is the plan, including the client's consent. The struck-through weight shows a correct paper correction: one line, still readable, marked and initialed.

Abbreviations

Standard abbreviations save space, but only if everyone reads them the same way. Common record abbreviations include Hx (history), Vx (vaccination), PE (physical exam), TPR (temperature, pulse, respiration), MM (mucous membranes), CRT (capillary refill time), BAR (bright, alert, responsive), BCS (body condition score), WNL (within normal limits), Dx and DDx (diagnosis and differential diagnosis), Rx (prescription) and Tx (treatment).8 Some abbreviations cause dosing errors. The Institute for Safe Medication Practices (ISMP) lists them as error-prone; Table 2 shows the ones that matter most in a veterinary record. New Jersey also requires that copies of a record sent out include a key to any codes and abbreviations used.7

Table 2. Error-prone notations and what to write instead
Do not writeHow it is misreadWrite instead
U or u (units)As 0 or 4, giving a 10-fold or greater overdose; or as ccunits
IUAs IV (intravenous)units
QD or q.d.As q.i.d. (four times a day)daily
1.0 mg (trailing zero)As 10 mg if the decimal point is missed1 mg
.5 mg (no leading zero)As 5 mg if the decimal point is missed0.5 mg
µgAs mgmcg
ccAs u (units)mL
AD, AS, AU (ears)As OD, OS, OU (eyes)right ear, left ear, each ear

Source: ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations.10

The veterinarian-client-patient relationship

The VCPR is the professional relationship between the client, the animal and the veterinarian. The federal definition in 21 CFR 530.3 has three parts.3

  1. The veterinarian has assumed responsibility for medical judgments about the animal, and the client has agreed to follow the veterinarian's instructions.
  2. The veterinarian knows the animal well enough to make at least a general or preliminary diagnosis.
  3. The veterinarian is readily available for follow-up if there is an adverse reaction or the treatment fails.

The same rule says this relationship exists only when the veterinarian has recently seen the animal, by examining it or by timely visits to the premises where the animals are kept.3 The AVMA notes that a few states now allow a VCPR to be set up electronically through telemedicine, but in those states an in-person exam or timely visits are still required for certain medications, health certificates and veterinary feed directives.2 A VCPR lapses if the recommended visits lapse, and the client may end it at any time.2

Why it matters for dispensing. Extralabel drug use under AMDUCA must be by or on the order of a veterinarian within a VCPR.12 A prescription animal drug may be dispensed only within a valid VCPR, and practice employees may not sell prescription drugs to walk-in customers who do not have one.4 The record is the evidence that the VCPR exists: it shows the date of the last exam and who examined the animal.

Procedure: writing and correcting a record entry

  1. Open the correct patient record. Check the patient name, client name and signalment before you write.
  2. Write the date and time, and identify yourself on the entry. Pennsylvania requires the record to identify the treating individual after each entry.5
  3. Record the Subjective data in the owner's terms: the complaint, how long it has been going on, diet, medications and vaccination history.
  4. Record the Objective data with units: temperature, pulse, respiration, weight, mucous membranes, CRT and any test you ran.
  5. Record treatments only after you give them, with drug, dose, route and time. Never chart a task in advance or chart a task as done when it was not.9
  6. Record client communication: estimates, consent or refusal, phone calls and discharge instructions.5
  7. On paper, do not leave blank lines that someone could fill in later.9
  8. If you make an error on paper, draw a single line through it, mark it as a mistaken entry and add your initials. Never erase, scribble or use correction fluid.9
  9. If you make an error in an electronic record, correct it so that the original error and the correction both stay visible in the system history.9 Use only your own login so the audit trail shows who made each entry.

Flowchart: can I release this record?

Records requests come by phone, email and walk-in. The technician's job is to recognize which requests can be handled under practice policy and which go to the veterinarian or practice manager. The AVMA Principles say record information is confidential and must not be released except as required or allowed by law, or with client consent.1 New Jersey's rule spells out four situations: release required by law, a request from the state board, client authorization, and release needed to protect the health of a person or an animal.7

Decision tree for releasing medical record information Request for record information Is the requester the client, or someone the client has authorized (for example a new vet)? Is release required by law (subpoena, court order) or requested by the state board? Is it needed to protect the health of a person or an animal (e.g. a bite case)? No No No Yes Yes Yes Do not release. Explain politely that client consent is needed. Note the request in the record. Release under practice policy Client: verify identity, provide copy. Law, board or health risk: refer to the veterinarian; release only what is needed. Document what was sent, to whom, when.
Figure 2. Decision tree for a records request. Release is allowed with client consent, when the law or the state board requires it, or when needed to protect human or animal health. Anything else waits for the client's consent. Every release is documented.

Two rules catch new staff out. First, the record belongs to the practice, but the client is entitled to a copy or summary: the AVMA says a veterinarian is obligated to provide copies or summaries when the client asks.1 Second, in Texas and Pennsylvania a practice may not withhold records because the client owes money.56 Deadlines vary: Pennsylvania requires release within 3 business days of a written request, New Jersey within 10 business days.57

Table 3. Retention and release rules in three states (examples only; check your own state)
StateMinimum retentionRelease to client
Pennsylvania3 years from the date the patient was last treatedCopy or summary within 3 business days of a written request; not withheld for unpaid fees
Texas3 years after the last visit, including radiographsCopies at reasonable cost within a reasonable time; not withheld for unpaid fees
New Jersey5 years from the last visit; 3 years from the last entry if the patient has diedCopy or summary within 10 business days of a written request, with a key to abbreviations

Sources: 49 Pa. Code 31.225; 22 Tex. Admin. Code 573.526; N.J. Admin. Code 13:44-4.9.7

Species differences

  • Dogs and cats: each patient has its own record. Signalment uses species, breed, age, sex and reproductive status, for example FS (spayed female) or MN (neutered male).8
  • Horses: sex terms may combine sex and reproductive status, such as stallion for an intact male or mare for a female.8
  • Livestock and litters: Texas allows records on a per-client basis, in a daily log or billing records, as long as the treatment details identify the animals and the care given.6 Pennsylvania requires production animal veterinarians to meet federal recordkeeping rules.5
  • Food animals and the VCPR: for herds, the VCPR can rest on timely visits to the premises where the animals are kept, not only on exams of each animal.3 Even where a VCPR may be set up electronically, issuing a veterinary feed directive still requires an in-person exam or timely visits to the operation.2

Calculation: working out a retention date

Problem. You work in New Jersey. A living cat was last seen on 9 May 2021. A coworker wants to shred the chart during a clean-out in October 2026. May the chart go?

Rule. New Jersey: 5 years from the last visit for a living patient.7

Working. 9 May 2021 + 5 years = 9 May 2026. October 2026 is after 9 May 2026.

Answer. The legal minimum has passed, so the chart may be destroyed if practice policy allows. If the cat had died and the last entry was 9 May 2021, the minimum would have been 9 May 2024 (3 years). In Pennsylvania or Texas the minimum for a living patient would also have been 3 years.

  • Confidentiality. Do not discuss a patient with neighbors, breeders, other clients or on social media. The AVMA says client confidences are kept unless the law requires disclosure or it is needed to protect people or animals.1
  • Records do not leave with you. Removing or copying records for personal gain without the client's and practice owner's permission is unethical.1 In Pennsylvania a departing veterinarian may not copy or remove records without the owner's consent.5
  • Consent and refusal. Write down what the client agreed to and what they declined. If a client declines radiographs, that refusal belongs in the Plan.5
  • Prescriptions. A client may ask for a written prescription instead of buying the drug at the clinic; the AVMA says veterinarians shall honor that request but may charge a fee where state rules allow.1
  • Explaining the VCPR to clients. When someone calls for a refill for a pet not seen in a long time, explain that the veterinarian needs a current relationship with the animal before prescribing, and offer an appointment. Telling them it is the law in most states is accurate.2

Common mistakes and exam traps

  • Putting the owner's report ("he seems painful") in Objective. It is Subjective. Your own pain score or a measured temperature is Objective.
  • Putting the differential diagnosis list in Plan. Differentials belong in Assessment.
  • Choosing "use correction fluid" or "black it out so it is neat." The correct answer always keeps the original entry readable.
  • Answering that records belong to the client. They belong to the practice; the client is entitled to copies.
  • Assuming one national retention period. There is none in this guide's sources: each state sets its own, and 3 and 5 years both appear.
  • Treating a technician's rapport with the client as a VCPR. Only the veterinarian can hold the VCPR.

Quick review

  1. The record plans care, communicates within the team and is legal evidence.
  2. SOAP: Subjective, Objective, Assessment, Plan.
  3. Subjective is what the owner reports; Objective is what you measured.
  4. Assessment holds the veterinarian's diagnosis or differentials.
  5. The POMR organizes the record by problem, each with its own SOAP.
  6. Every entry has a date and the writer's identity.
  7. Correct paper errors with one line, a note and initials; never erase or cover.
  8. Write "units", "daily", "mcg" and "mL"; use a leading zero and no trailing zero.
  9. Records belong to the practice and are confidential; clients may have copies.
  10. Release without consent only when law, the board or a health risk requires it.
  11. Retention is set by state law: 3 years in PA and TX, 5 years in NJ.
  12. No valid VCPR, no dispensing or prescribing of prescription drugs.

Test yourself

5 questions written for this guide. Pick an answer, then check it.

Question 1A technician is writing the SOAP note for a cat presented for weight loss. Which entry belongs in the Objective section?

Show answer

Answer: B. Body weight 3.4 kg, down from 4.1 kg in March

B is a measured value, so it is Objective data. A is the owner's report, which is Subjective. C is the veterinarian's differential list, which belongs in Assessment. D is a diagnostic step, which belongs in Plan.

Source 6.3 Medical Record and Disease Terminology, SOAP Notes, Introduction to Veterinary Terminology, Open Education Alberta

Question 2While charting on a paper record, you write the wrong drug in a treatment entry. What is the correct way to fix it?

Show answer

Answer: D. Draw one line through it, mark it mistaken, initial it

D keeps the original entry readable and shows who corrected it. A and B hide the original, which looks like falsification. C destroys part of the legal record.

Source 2.5 Documentation, Legal Documentation, Nursing Fundamentals 2e, Open RN

Question 3Which situation meets the federal definition of a valid veterinarian-client-patient relationship (VCPR)?

Show answer

Answer: A. The veterinarian examined the dog last month, the client follows her instructions, and she is available for follow-up

A has all three parts in 21 CFR 530.3: responsibility and client agreement, enough recent knowledge of the animal, and availability for follow-up. B: only a veterinarian can hold a VCPR. C: paperwork and payment do not create one. D: the veterinarian has not recently seen the animal, so the VCPR has lapsed.

Source 21 CFR 530.3(i), Definitions, Electronic Code of Federal Regulations

Question 4A breeder calls asking for a puppy's vaccination and exam records. The puppy now belongs to your client, who has not authorized any release. No law or health risk is involved. What should you do?

Show answer

Answer: C. Decline and explain the client's consent is needed

C is correct: record information is confidential and is released only with client consent or when the law or a health risk requires it. A and D release confidential information without consent. B is still a release; reading aloud is disclosure.

Source Principles of Veterinary Medical Ethics, Confidentiality and record keeping, AVMA

Question 5Your practice is in New Jersey, where records of a living patient must be kept 5 years from the last visit. A living dog was last seen on 12 August 2022. What is the earliest date the record may legally be destroyed?

Show answer

Answer: B. 12 August 2027

12 August 2022 plus 5 years is 12 August 2027. A uses 3 years, which applies in New Jersey only to a deceased patient, or to living patients in states such as Pennsylvania and Texas. C and D add 7 and 10 years, which are not the New Jersey rule.

Source N.J. Admin. Code 13:44-4.9(e), Patient records, New Jersey State Board of Veterinary Medical Examiners

0 of 5 answered

Practise this topic

Two questions from our VTNE practice bank on this topic.

Question 1A veterinary technician is writing a patient progress note in SOAP format. What do the four letters of SOAP stand for?

Show answer

Answer: D. Subjective, Objective, Assessment, Plan

SOAP stands for Subjective, Objective, Assessment, and Plan. The subjective section holds information such as the owner's chief complaint and what the owner has observed at home. The objective section records measurable findings, including physical examination results and diagnostic test results. The assessment gives the clinical evaluation and differential diagnoses, and the plan lays out the next steps in management.

Signs and Observations sound reasonable but are not the SOAP headings, and they blur the key split between what the owner reports and what the team measures. Summary, Objectives, Actions, and Prognosis is not the SOAP structure either. Signalment, Overview, and Progress are all parts of a full medical record, since signalment and history belong in every record, but they are not what the letters of SOAP stand for.

Source Speech recognition tools for veterinary case learning (Yogo T et al., 2025), Frontiers in Veterinary Science (open access)
Writing as a Veterinary Technician, Purdue Online Writing Lab, Purdue University

Question 2Which of the following best defines a Veterinarian-Client-Patient Relationship (VCPR) as it pertains to legal prescribing authority?

Show answer

Answer: D. The DVM recently examined the animal and accepts responsibility

Under the federal definition in 21 CFR 530.3, a valid VCPR exists when the veterinarian has assumed responsibility for medical judgments and the client agrees to follow instructions, the veterinarian knows the animal well enough to make at least a preliminary diagnosis, and the veterinarian is readily available for follow-up if the treatment fails or causes adverse reactions. That relationship can exist only when the veterinarian has recently seen the animal through an examination or timely visits to the premises. These elements are what allow the veterinarian to prescribe.

Telemedicine alone cannot establish a VCPR in most states; the AVMA notes that only a few states allow the relationship to be set up electronically. Rapport between a technician and a client is not a VCPR, because the relationship is with the veterinarian who takes responsibility for the patient. A signed form and a paid fee are administrative steps and do not show that any veterinarian has examined the animal.

Source 21 CFR 530.3 Definitions, Legal Information Institute, Cornell Law School
The veterinarian-client-patient relationship (VCPR), American Veterinary Medical Association

Practise all 18 questions on this topic Free account. Or try the free practice quiz.

Figure credits

  • Figure 1 Original diagram, VTNE Exam Prep
  • Figure 2 Original diagram, VTNE Exam Prep

References

  1. American Veterinary Medical Association. Principles of Veterinary Medical Ethics of the AVMA. avma.org (accessed 2026-10-31) avma.org/resources-tools/avma-policies/principles-veterinary-medical-ethics-avma
  2. American Veterinary Medical Association. The veterinarian-client-patient relationship (VCPR). avma.org (accessed 2026-10-31) avma.org/resources-tools/pet-owners/petcare/veterinarian-client-patient-relationship-vcpr
  3. Electronic Code of Federal Regulations. 21 CFR 530.3, Definitions (valid veterinarian-client-patient relationship). law.cornell.edu (accessed 2026-10-31) law.cornell.edu/cfr/text/21/530.3
  4. US Food and Drug Administration, Center for Veterinary Medicine. FDA Regulation of Animal Drugs. fda.gov (accessed 2026-10-31) fda.gov/animal-veterinary/resources-you/fda-regulation-animal-drugs
  5. Pennsylvania State Board of Veterinary Medicine. 49 Pa. Code 31.22, Recordkeeping. law.cornell.edu (accessed 2026-10-31) law.cornell.edu/regulations/pennsylvania/49-Pa-Code-SS-31-22
  6. Texas Board of Veterinary Medical Examiners. 22 Tex. Admin. Code 573.52, Veterinarian Patient Record Keeping. law.cornell.edu (accessed 2026-10-31) law.cornell.edu/regulations/texas/22-Tex-Admin-Code-SS-573-52
  7. New Jersey State Board of Veterinary Medical Examiners. N.J. Admin. Code 13:44-4.9, Patient records. law.cornell.edu (accessed 2026-10-31) law.cornell.edu/regulations/new-jersey/N-J-A-C-13-44-4-9
  8. Open Education Alberta. Introduction to Veterinary Terminology, 6.3 Medical Record and Disease Terminology. pressbooks.openeducationalberta.ca (accessed 2026-10-31) pressbooks.openeducationalberta.ca/veterinarymedicalterminology/?p=1568
  9. Open RN, Chippewa Valley Technical College. Nursing Fundamentals 2e, 2.5 Documentation. wtcs.pressbooks.pub (accessed 2026-10-31) wtcs.pressbooks.pub/nursingfundamentals/chapter/2-5-documentation/
  10. Institute for Safe Medication Practices. ISMP List of Error-Prone Abbreviations, Symbols, and Dose Designations. ismp.org (accessed 2026-10-31) online.ecri.org/hubfs/ISMP/Resources/ISMP_ErrorProneAbbreviation_List.pdf
  11. American Association of Veterinary State Boards. 2023 Veterinary Technician National Examination Content Outline. aavsb.org (accessed 2026-10-31) aavsb.org/wp-content/uploads/2025/04/AAVSB-2023-Veterinary-Technician-National-Examination-Content-Outline-2.pdf
  12. US Food and Drug Administration. Animal Medicinal Drug Use Clarification Act of 1994 (AMDUCA). fda.gov (accessed 2026-10-31) fda.gov/animal-veterinary/acts-rules-regulations/animal-medicinal-drug-use-clarification-act-1994-amduca
  13. Kanemaki N. Clinical Reasoning in Veterinary Ophthalmology: A Pathophysiology-Centered Framework for Canine and Feline Clinical Practice. Animals (Basel). 2026;16(20):3185. PMC13700552 pmc.ncbi.nlm.nih.gov/articles/PMC13700552/

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