How to Document Veterinary Physical Exams with AI
Learn how to efficiently document physical examination findings using VetGeni's AI veterinary scribe - from vitals to all 14 organ systems.
Physical Exam Documentation with VetGeni AI Veterinary Scribe
14 Organ Systems Covered
Two Ways to Document Your Exam
VetGeni offers two approaches to physical exam documentation, designed to fit different workflows:
1. Voice Recording (Hands-Free)
Start recording, describe your findings as you examine the patient, and let VetGeni's ai veterinary scribe extract and organize the information into the appropriate organ system categories.
2. Quick-Click Normal Exam
For routine wellness exams where everything is normal, use the one-click “All Normal” button to populate standard findings, then edit only the sections with abnormalities.
Automatic Pain Score Derivation
VetGeni automatically derives a CSU pain score (0-4 scale) based on your examination findings. The system looks at indicators like posture, response to palpation, and mobility to suggest an appropriate pain level.
The pain score appears in your documentation with its source clearly marked - whether it was stated by you, derived by AI, or not assessed.
Integration with SOAP Notes
Physical exam findings automatically flow into the Objective section of your SOAP note. This bidirectional sync means you never have to enter the same information twice - changes in one place update the other.
Learn more in our Creating SOAP Notes tutorial.
Video Transcript
“Let me show you how to document a physical exam in VetGeni. This is where the AI veterinary scribe really shines.”
“First, I'll enter the vitals. Temperature, pulse, respiration, weight. These fields accept the values directly - just type them in.”
“Now for the exam itself. I have two options. If this is a wellness check and everything is normal, I can click 'All WNL' - within normal limits - and it populates all 14 organ systems with standard normal findings.”
“But today Remington has a laceration, so I'll use the voice recording option. I tap the microphone and describe what I see: 'Two centimeter laceration on the right forelimb, moderate swelling, no active bleeding, wound margins are clean, mild pain on palpation of the surrounding area.'”
“VetGeni transcribes that and places it in the integumentary section automatically. It also notices I mentioned pain, so it flags that for the pain assessment section.”
“I continue through the exam. For normal systems, I just say 'cardiovascular WNL, respiratory WNL' and so on. The AI understands the shorthand.”
“When I'm done, I can review everything organized by body system. Each abnormal finding is highlighted. The pain score is derived automatically based on what I described - in this case it suggests a 2 out of 4 for mild to moderate discomfort.”
“This whole process takes less than two minutes, and the documentation is ready to flow into my SOAP note. That's efficient physical exam documentation with VetGeni.”
Try AI Physical Exam Documentation
See how VetGeni's ai veterinary scribe streamlines your physical exam workflow.