Use 'The Exam Room 6' for better medicine at your veterinary practice


This pocket card can serve as an aid for exam room effectiveness. I bring mine with me for each appointment

"I find that it is not the circumstances in which we are placed, but the spirit in which we face them, that constitutes our comfort." — Elizabeth T. King

Is "The Exam Room 6" a new Ocean's 11? No, Brad Pitt and George Clooney won't be making it into most of our exam rooms any time soon. "The Exam Room 6" is about a big job helped out by a little card.

This pocket card can serve as an aid for exam-room effectiveness. I take this little card into exam rooms with me and put it on the counter as an "eyestop" to help me stay on target.

Clients noticed improvements. I asked better questions, and I was more attentive and thorough. Certainly, we are all up to speed on exam-room etiquette: Enter the room; introduce yourself; say good morning to the client and patient.

At the end of the visit, don't forget to say goodbye and a offer a sincere thank you.

But that's not all there is to exam room duties.

Pocket full of duties

These are the six essential steps for exam room medical duties to be accomplished efficiently, succinctly, thoroughly and consistently.

So often we see a pet for a simple problem and then tend to glide over other issues. The pocket card can keep us focused.

The six steps are:

> Prep

> What

> Assess

> Plan

> Next Appointment

> Proof.

Let's review them one by one.

Step 1: Prep

Enter the exam room fully prepared after reviewing the master problem list that addresses why the pet is here today. Also, look at the laboratory data in this patient's file.

When you finally enter the room, the client will be impressed that you remembered the pet had a pancreatitis attack in 2006.

Step 2: What

"What is going on" must be ascertained. Sit and interview the client. You should focus the conversation on two issues.

First, the client has a story to tell—so a veterinarian must sit, listen and not interrupt. All that prep outside the exam room helps facilitate the discussion.

Second, look at the physical evidence. With each patient and with each visit, the same examination template is to be followed. You know that diagnoses are built on a comprehensive history and a complete physical exam. Make sure all nine of these items are addressed at every visit: weight, body score, pain score, dental score, behavior concerns, retina, tympanic membranes, heart rate and sounds and physical mobility.

Step 3: Assess

Now the heat is on. The assessment is time to make a differential list and render a prognosis. It's possible to create at least five possible diagnoses to rule out for almost any patient. But this list is as essential for the client to understand as it is for the veterinarian and veterinary team members to work with. Clients will appreciate the need for timely screening tests when the diagnosis is cloudy—and with five possible issues, the diagnosis is cloudy.

In other words, the "let's try this" mentality can get us into trouble. The prognosis is but an opinion as to the potential outcome. Clients to know this so they can make informed choices about diagnostic tests.

The ear with an established yeast infection will carry a poor prognosis when treated with generic ear drops twice a day. The prognosis becomes good when ketoconazole is added. Clients will go with the ketoconazole when faced with the reality.

Step 4: Plan

Here's where the rubber meets the road. Any plan for treatment must be succinct, and the clinician must be able to explain it to the client.

Recommendations come in three areas: immediate treatment, diagnostic testing, and therapy.

It's not uncommon for us to have a triage mentality at the start, when we're assessing immediate needs like pain management.

Next, we need to create a diagnostic testing algorithm for the patient. Recommendations can be presented as either immediately necessary or possible as the case unfolds.

Then we arrive at the indicated and recommended therapy plan: surgery and/or medical management.

Step 5: Next appointment

Patients deserve to have the next appointment scheduled before they leave.

Remember that patient care is never-ending. While many health problems might not need specific follow up, there will always be other problems that develop.

The next appointment's goals should always be specific. What's indicated for the condition? What do you recommend? Will it be an outpatient visit or an inpatient visit? Will there be testing? The client needs to know what's recommended and the relative priority of the particular recommendations. The next apointment might be a crucial follow-up for surgery or just an annual heartworm test six months down the road. And if clients delay, make a notation in the medical record so that you can talk about the health implications.

Specifics also prevent the team from having to guess why the next visit was scheduled. Fewer guesses mean clients and staff are more likely to be on the same page. This inspires confidence.

Step 6: Proof

Don't think proof as in proof of a crime was committed. Think proof as in proofreading or fact checking. The record needs to be audited for completeness.

> Was the template followed?

> Was the prognosis made according to protocol?

> Were the right drugs prescribed?

> Did the doctor follow through on all the previous five steps?

At this time, you can also check that the "Three Visit Rule" was followed. When a patient presents three times for an issue, the doctor should revisit the issue, confirm the diagnosis or seek a second opinion. The client will appreciate the concern.

The proof step also assures the clinic that protocols, logs, entries and a final diagnosis have been addressed and entered.

The proof enables veterinarians to view and review each other's work for completeness of thought, differentials, diagnostics and scheduling the next appointment.

Try the "Exam Room 6" at your clinic (you can download cards ready to print at and watch client satisfaction rise, along with the decreased stress of never having to ask yourself: Did I do it all in there? The answer will be, yes!

Dr. Riegger owns Northwest Animal Clinic in Albuquerque, N.M. He can be reached at, by e-mail at or by calling (505) 898-1491.

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