Equine medical records: What should be documented during each visit?

In everyday equine veterinary practice, every visit adds an important chapter to a horse’s medical history. When information is scattered across notebooks, messages, and files, it can be difficult to quickly retrieve previous observations, determine which examinations have been performed, and track how a case has progressed.

Well-organized medical records help veterinarians monitor patients over time and facilitate communication when other professionals become involved in their care. They also make it easier to review a horse’s medical history before a follow-up visit.

What Should Be Documented During Each Visit?

Start with the information that identifies the visit and the patient: date, time, and location; identification of the attending veterinarian; and identification of the horse and its owner or caretaker.

For horses, details such as name, sex, breed, age, coat color, distinguishing markings, microchip number, or registration information can help ensure accurate patient identification.

Next, document the reason for the visit and the information provided by the owner or caretaker, including relevant medical history.

Record observations regarding the horse’s general condition and the clinical parameters assessed, along with findings from the medical history, physical examination, and any laboratory or diagnostic imaging tests.

The veterinarian’s clinical assessment, procedures performed, vaccinations, and observed progress should also be documented.

When applicable, include both the presumptive and definitive diagnoses.

Recording the date, time, and identity of the professional performing each procedure helps maintain a clear chronological record. Reports from additional diagnostic tests should also be attached to the patient’s medical record.

Brazilian Federal Council of Veterinary Medicine (CFMV) Resolution No. 1,321/2020, as subsequently amended, specifies the information that must be included in veterinary medical records, such as visit details, information provided by the owner or caretaker, clinical findings, diagnoses, procedures, and diagnostic reports.

Veterinarians should consult the current regulations and official templates to ensure their records comply with the requirements applicable to their professional practice.

Document Clearly and at the Time of the Visit

Keep clinical notes objective, comprehensive, and organized in chronological order.

Document observed facts and clearly distinguish them from information reported by the owner or caretaker.

If information needs to be corrected, make sure the correction preserves the integrity of the medical history and complies with applicable professional regulations.

For field visits, establishing a simple documentation routine can make a significant difference:

Identify the horse, record the reason for the visit, document clinical findings and procedures, attach relevant test results, and include the information necessary for ongoing care.

Consistent recordkeeping can be valuable for future consultations and for communication among the professionals involved in the case.

How Can Technology Help?

Digital tools can make it easier to organize and access patient information across veterinary visits, provided that records remain complete, up to date, and securely protected.

An application like GENNO can support this process by bringing essential patient information together in one place, reducing reliance on scattered notes and disconnected records.

Technology is intended to support clinical practice, not replace professional judgment. Clinical assessments, medical decisions, and responsibility for maintaining accurate medical records remain with the attending veterinarian.

A good medical record does not need to be complicated.

What matters most is ensuring that every visit produces a clear, chronological, and useful record that supports the horse’s ongoing care.

Keeping information organized also helps ensure continuity of care.

References

Federal Council of Veterinary Medicine (CFMV). Resolution No. 1,321, April 24, 2020, as subsequently amended.

https://manual.cfmv.gov.br/arquivos/resolucao/1321.pdf

Federal Council of Veterinary Medicine (CFMV). Documenting Professional Practice: An Important Ally.

https://revista.cfmv.gov.br/o-registro-da-atuacao-profissional-um-importante-aliado/

AAEP et al. Guidelines for Equine Veterinary Case Referral.

https://aaep.org/resource/guidelines-for-equine-veterinary-case-referral/