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Clinical Documentation

Generate Veterinary SOAP Notes in Seconds

Transform your clinical narrative into structured Subjective, Objective, Assessment, and Plan sections. Voice or text input, your choice.

No account required to try. Full editing control.

See What VetGeni Generates

Example SOAP note from a foreign body case

Example Output

Generated in 8 seconds

Subjective

Mia, a 5-year-old female spayed German Short-Haired Pointer, presents for possible gastrointestinal obstruction after ingestion of a sock with regular liquid vomiting since last night. History includes prior sock ingestion and exploratory laparotomy; no home medications are prescribed. The owner requests surgical intervention.

Objective

Vitals: Weight: 55.2 pounds Hydration: Mildly dehydrated (~5-6%) CSU Pain Score: 0/4 Mucous Membranes: mildly tacky Physical Exam: General: Quiet, alert, responsive (QAR). Eyes, Ears, Nose, Throat (EENT): Eyes clear, ears clean, nose moist, throat normal. Skin: Mild skin tent noted; coat clean; no lesions, masses, or parasites. Musculoskeletal: Ambulating normally; no lameness, pain, or swelling. Cardiovascular: Heart rate and rhythm normal; no murmurs; strong synchronous pulses. Respiratory: Breathing normal; lungs clear bilaterally; no coughing or wheezing. Gastrointestinal: Abdomen tense on palpation; no masses or organomegaly; normal bowel sounds. Urogenital: No abnormalities; bladder palpates normal; no abnormal discharge. Neurological: Alert and appropriate; gait normal; reflexes and proprioception normal. Lymphatic: No peripheral lymphadenopathy. Oral Cavity: Gums mildly tacky; minimal tartar; no oral lesions or masses.

Assessment

Diagnostics: 1. Radiographs: Suspected foreign material in the duodenum Problem List: 1. History of foreign body ingestion (sock) 2. Radiographic evidence of foreign material in the duodenum Differentials: Gastrointestinal Foreign Body Obstruction (Duodenal, Sock) vs. Functional Ileus (Secondary to Prior Obstruction) vs. Gastroenteritis (Foreign Body-Induced) vs. Intestinal Stricture (Post-Foreign Body)

Plan

Client Communication: Mia presented for possible gastrointestinal obstruction after a suspected sock ingestion, with recent onset vomiting. X-rays showed likely foreign material in the duodenum, and prior blood work showed mild dehydration. Owners consented to exploratory surgery. An exploratory laparotomy revealed a sock lodged just past the stomach with mild bruising; no dead or severely damaged intestine. During hospitalization, Mia received pain management, antibiotics, IV fluids, and GI support. Hospitalized 24-36 hours for monitoring and supportive care, with plans for discharge once eating well. Treatments: 1. Methadone: 0.2 mg/kg, IV 2. Dexmedetomidine: 0.005 mg/kg, IV 3. Propofol: 4 mg/kg, IV to effect 4. LRS (Lactated Ringers): 5 mL/kg/hour, IV 5. Cefazolin: 22 mg/kg, IV intraop 6. Cerenia (Maropitant): 1 mg/kg, IV, q24, first dose at 2 a.m. 7. Famotidine: 1 mg/kg, IV, q12, first dose at 2 a.m. 8. Metoclopramide: 0.5 mg/kg, IV, q8 9. Exploratory laparotomy with single enterotomy and foreign body removal: foreign body was a sock 10. Abdominal closure: performed as described Medications: No medications prescribed.

How It Works

Three steps to better documentation

1

Input Your Notes

Record audio or type your clinical observations, history, and exam findings.

2

AI Structures It

VetGeni extracts and organizes information into S, O, A, and P sections.

3

Review and Export

Edit any section, add details, then export to your records or print.

Built for Veterinary Workflows

Voice to Text

Dictate notes hands free during or after exams.

14 Organ Systems

Physical exam findings organized consistently.

Species Specific

Tailored language for dogs, cats, and more.

Fully Editable

Complete control over every section.

Pain Scale Support

CSU pain scores when exam supports it.

Template Library

Standardize documentation across your team.

Frequently Asked Questions

Can I edit the generated SOAP note?

Yes. Every section is fully editable before you save or export. You maintain complete control over the final documentation.

Does it work for both dogs and cats?

Yes. VetGeni supports species specific terminology and can tailor language for dogs, cats, and other small animals.

Can I use voice input?

Yes. Record your notes verbally and VetGeni will transcribe and structure them into SOAP format.

How accurate is the AI extraction?

VetGeni uses veterinary trained models to categorize clinical information. Always review outputs before finalizing.

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