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GuidesWhat should an electronic animal record contain?
An electronic animal record is the one place where a practice finds who the animal is, who owns it and what has been done. Keep it complete, short to read and tied to the owner.
Short answer
- Identity: name, species, breed, date of birth, sex and microchip number.
- Owner: name, phone and e-mail, linked to the animal.
- Safety: allergies and notes that every vet must see.
- History: each consultation with reason, symptoms, diagnosis, treatment and the follow-up date.
- Documents: a list of lab results, images, referrals and certificates, with a date and where they are kept.
The core of the record
| Field | Why it matters |
|---|---|
| Name and reference number | Finds the right animal when names repeat |
| Species, breed, sex, date of birth | Sets dosing, vaccine choice and risk |
| Microchip number | Confirms identity and lets you search by chip |
| Owner name, phone, e-mail | Lets you reach the right person |
| Allergies and notes | Warns the next vet before a treatment |
Consultations and prescriptions
Write each consultation as a short note: the reason for the visit, the symptoms, the diagnosis, the treatment and the date of the next check. Free text is faster at the desk than a coded list, though it is harder to report on.
A prescription is a document. Record the medication, dose and instructions, and keep a copy in the record. Whether a printed sheet is enough depends on the rules that apply to you.
Documents: record that they exist
Lab results, images, referral letters and vaccination certificates are often large files. Many practices keep the files in one system and list them in the record with a title, a type, a date and a link.
- Always note the date and the type of each document.
- Link to the file, so the record stays small.
- Keep the originals where you can back them up.
How 4softvet handles it
- An animal file holds name, species, breed, date of birth, sex, microchip number, allergies and notes, linked to the owner.
- Consultation notes are free text. There is no coded diagnosis list.
- A prescription is printed with a line for signature and stamp. Your copy stays in the file. It is not sent to any registry.
- The documents register keeps a title, type, date and link. It does not store the files.
Privacy
Owner contact details are personal data. The practice is usually responsible for them under the privacy law that applies to you, for example the GDPR in the EU and the UK. Software helps you keep them in order; it does not certify compliance.