> ## Documentation Index
> Fetch the complete documentation index at: https://docs.rescueconsole.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Medical records
> The Medical tab in depth: diagnoses, tests, vaccines, treatments, exams, procedures, medications, recurring items, weights, and the Medical due page.
Everything done to an animal's body, and everything still to do, is kept on the **Medical** tab of its [record](/animals/record). The **Medical due** page gathers what is outstanding across every animal. Anyone who can **See** Animals can read both; adding, finishing and deleting records needs **Change** on Animals.
The lists the forms pick from (diagnoses, tests, vaccines, treatments, procedures, conditions and medications) are your rescue's own, kept under **Settings → Animal management → Medical**. See [Animal management](/settings/pet-configuration).
## The Medical tab
The tab is a column of cards, each holding one kind of record.
| Card | What it holds |
| ---------------------------- | -------------------------------------------------------------------------------- |
| **Summary** | Spay or neuter, and the numbers at a glance. |
| **Diagnoses** | What a vet or your own staff have found. |
| **Diagnostic tests** | Tests run or scheduled, with their results. |
| **Vaccines** | Given or scheduled, with the lot, the method and the site, and the next one due. |
| **Treatments** | A course at a time: the route, the amount, how often and for how long. |
| **Physical exams** | A vet or tech exam, done or scheduled. |
| **Procedures and surgeries** | Requested or done, several to a visit. |
| **Medical records** | Medications and preventatives. |
| **Weight history** | Every weight, the change between them, and a chart. |
## Summary
**Spay / neuter** says whether the animal is spayed or neutered and, when it is, whether that was **Before intake** or **In our care**, the date, the clinic and the veterinarian. Press **Edit** on the card to change them. A procedure your catalogue marks as a spay or neuter fills these in by itself when it is done (see [Procedures and surgeries](#procedures-and-surgeries)).
For a cat, the card also keeps **Declawed** (Yes, No or Not recorded) and **FIV** (Positive, Negative or Not tested).
**At a glance** counts what needs attention:
| Line | What it counts |
| ---------------------- | -------------------------------------------------------------------- |
| **Latest weight** | The last reading and its date, with the change since the one before. |
| **Awaiting results** | Tests not yet run. |
| **Due or overdue** | Items due today or earlier that are not done. |
| **Active medications** | Medications not yet marked given. |
| **Diagnoses on file** | Every diagnosis on the record. |
## Given, done or scheduled
Every form starts with the same question: has it happened, or is it being booked? The first choice reads **Already given**, **Already run**, **Already done** or **Started**, depending on the card. The other is always **Schedule it**.
Scheduling asks for **Due on**, a **Time** (nine in the morning unless you change it) and a **Length**, from 15 minutes to **All day**. A scheduled item:
* appears on the animal's **Today** tab once it is due, on the [Medical due](#the-medical-due-page) page, and on the [Calendar](/everyday/calendar);
* creates an open task on the animal, named for the animal and the item, assigned to the person named as doing it, or otherwise to you. See [Tasks](/everyday/tasks). Finishing the item finishes the task, and deleting the item deletes it.
## Where it was done
Most forms ask where the work happened.
* Tick **Our own clinic** for work done by your own team. You are then asked **Who did it** (or **Who will do it** for a scheduled item), which starts as you.
* Otherwise choose the **Veterinary practice**, then the **Veterinarian** (or **Surgeon**, on a procedure). The list of vets holds the people currently recorded at that practice, so pick the practice first. Practices and the people at them are kept under [Organizations](/organizations/list).
## Diagnoses
Press **Add a diagnosis**.
| Field | What it means |
| ---------------- | ------------------------------------------------------------------------------------------------------------------------- |
| **Diagnosis** | Required. Chosen from your catalogue, so it reads the same on every record. **Something else…** lets you type a **Name**. |
| **Diagnosed on** | Starts at today. |
| **Notes** | Anything to add. |
| **Diagnosed by** | Starts as you. |
Press **Save diagnosis**. A diagnosis can also be added from an exam (see [Physical exams](#physical-exams)).
## Diagnostic tests
Press **Add a test**, then choose **Already run** or **Schedule it**.
| Field | What it means |
| --------------------- | -------------------------------------------------------------------------------------------------------------- |
| **Test** | Required. From your catalogue, or **Something else…** and a **Name**. |
| **Run on** | For a test already run. Required. |
| **Outcome** | Awaiting results, Normal, Abnormal, Positive, Negative or Inconclusive. |
| The test's own fields | The results the test is made of, as your catalogue describes it: a count with its unit, a yes or no, a choice. |
| **Notes** | Anything to add. |
Press **Save test**, or **Schedule test**. A scheduled test reads **Scheduled for** its date. A test's badge turns green for Normal or Negative and amber for Abnormal or Positive.
### Entering results
When results come back, press **Enter results** on the test (or **Edit results** to correct them). Fill in **Run on**, **Outcome**, the test's fields and **Notes**, and press **Save results**.
## Vaccines
Press **Add a vaccine**, then choose **Already given** or **Schedule it**.
| Field | What it means |
| ------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------- |
| **Vaccine** | Required. From your catalogue, or **Something else…** and a **Name**. |
| **Given on** | For a vaccine already given. Required. |
| **Time** | The time it was given. |
| **Lot number** | From the vial. |
| **Product expiry** | The vial's expiry date. |
| **Method** | Subcutaneous, Intramuscular, Oral or Intranasal. |
| **Site** | Where it was given, such as Interscapular or Right hind leg. |
| The vaccine's own fields | Whatever your catalogue adds for that vaccine, such as **Rabies tag #**. |
| **Next due** | When the next one is due. Type a date, or fill in **Every** and **Unit** ("in 1 year") and the date is worked out from the day it was given. |
| **Notes** | Anything to add. |
Press **Save vaccine**, or **Schedule vaccine**.
When you give a **Next due**, the next dose is saved as its own scheduled record, so it comes due on its own. If you filled in **Every** and **Unit**, it also repeats: marking it done schedules the one after. See [Recurring items](#recurring-items).
## Treatments
Press **Add a treatment**, then choose **Started** or **Schedule it**.
| Field | What it means |
| -------------------------------- | -------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Treatment** | Required. From your catalogue, or **Something else…** and a **Name**. |
| **Medication** | The drug and strength, from your medication catalogue. Choosing one with **Something else…** and no name names the treatment after the medication. |
| **Started on** | For a course already started. Required. |
| **Route** | Oral, Topical, Subcutaneous, Intramuscular, Intravenous, Ophthalmic, Otic, Intranasal or Rectal. |
| **Amount**, **Unit** | The dose, such as 5 mL or 1 tablet. |
| **Frequency** | From Once to Monthly. |
| **Time due** | The time of day a dose is due. |
| **Duration (days)** | How long the course runs. |
| **Total doses**, **Doses given** | For counting a course down. |
| **Last dose** | Left empty, it is worked out from the start and the duration: a three-day course started on the 1st ends on the 3rd. |
| **Notes** | Anything to add. |
Tick **Schedule a follow-up exam** to book a recheck at the same time. It asks for the date, time and length, who requested it, the **Clinic**, an **Exam reason** and **Notes**, and whether it is a **Vet exam** or a **Tech exam**. The follow-up is saved as its own scheduled exam.
Press **Save treatment**, or **Schedule treatment**.
## Physical exams
Press **Add an exam**, then choose **Already done** or **Schedule it**. A scheduled exam keeps only the request; the findings are recorded when it is done.
| Section | Fields |
| ----------------------- | ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| The request | **Type** (Vet exam or Tech exam), **Reason** (Intake, Recheck, Labwork review, Check incision, Weight loss, Inappetence, Suspect URI, Quarantine release or Other), **Time**, **Requested by**. |
| When and who | **Done on** (required for an exam already done), **Performed by**, and [where it was done](#where-it-was-done). |
| **Vitals** | **Scope**, **Weight**, **Weight unit**, **Body condition score** (on a scale of 1 to 9), **Temperature**, **Temperature unit**, **Heart rate**, **Respiration**. |
| Findings | Press **Show findings** for mucous membranes, CRT, hydration, attitude, pain, and each body system from eyes to integument. |
| **Assessment and plan** | **Subjective**, **Objective**, **Assessment**, **Plan**. |
| **Diagnoses made** | Press **Add a diagnosis** for each, with its notes. |
An exam does more than save itself:
* A **Weight** on it is added to the weight history, noted with the exam's name.
* Each diagnosis made becomes a diagnosis on the record, dated the day of the exam.
* **Schedule a follow-up exam** and **Schedule a tech exam** each book a further exam as its own scheduled record.
Press **Save exam**, or **Schedule exam**. On the card, an exam shows its main vitals and assessment; **Show everything** opens the rest.
## Procedures and surgeries
Press **Add a procedure**. It starts on **Schedule it**, because a procedure is usually requested before it is done.
| Field | What it means |
| ------------------------------------------------------ | -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- |
| **Requested by**, **Requested on**, **Time**, **Memo** | The request, shared by every procedure of the visit. |
| **Done on**, or **Due on** | The day of the visit. |
| Where it was done | With **Surgeon** in place of **Veterinarian**. |
| **Procedure** | Required. From your catalogue, or **Something else…** and a **Name**. |
| **Surgery** | For a procedure already done: **Start**, **End**, **Extubated**, **Anesthesia**, **Delivery**, **Suture size**, **Suture type**, **Ligation**, **Closure**, **Skin glue**, **Tattoo**, **Castration**, **Routine**, **Complications**. |
| **Notes** | Anything to add. |
Press **Add another procedure to this visit** for each further procedure. Each becomes its own record with the same date and place.
When your catalogue marks a procedure as a spay or neuter, the form says so, and once the procedure is done the animal's **Spay / neuter** summary is set to Yes, in your care, with the date, the clinic and the vet.
## Medications and preventatives
The **Medical records** card holds everything that does not have a card of its own. Press **Add record**.
| Field | What it means |
| ----------------------------------------- | --------------------------------------------------------------------------------------------------------------------------------------- |
| **Type** | Medication or Preventative. |
| **Name** | Required. |
| **Performed on** | The day it was given. Leave it empty if it has not been given yet. |
| **Next due** | When it is due. |
| **Notes** | Anything to add. |
| **Veterinary practice**, **Veterinarian** | Who prescribed or gave it. |
| **From the catalog** | Medications only. Picks the exact drug and strength from your medication catalogue, and names the record after it if **Name** is empty. |
| **Refills** | Medications only. How many refills are left. Leave it empty if you do not track them. |
| **Prescription expires** | Medications only. |
| **This repeats** | With **Every** and **Unit** (days, weeks, months or years). |
Press **Save record**.
A record with a **Performed on** date is finished, and its **Next due** never comes due. To book an item, or to start one that repeats, leave **Performed on** empty and fill in **Next due**.
A medication with no **Performed on** date counts as an active medication in the summary.
## Recurring items
A recurring item is one that is scheduled again each time it is done: a yearly booster, a monthly flea treatment. It shows **Every year**, **Every 3 months** and so on beside its date.
The next occurrence is created when you mark the current one done, and it is dated from the day it was actually given, not from the day it was due. A rabies booster given two weeks late moves next year's booster two weeks later too. A month added to the 31st lands on the last day of a shorter month.
For a medication, the chain stops by itself when there is nothing left to give:
* when **Refills** reaches zero, marking it done says "No refills left: this prescription needs renewing.";
* when the next date would fall after **Prescription expires**, it says "The prescription has expired and needs renewing."
Each occurrence uses one refill.
### Stop repeating
**Stop repeating** on a recurring item ends the whole series: marking an item in it done no longer schedules another. Nothing already given is removed, and the item then reads **Recurrence ended**. An occurrence that was already scheduled stays until you mark it done or delete it.
## Completing an item
An item that is due and not done has a **Mark done** button. It opens the item's own fields so you can record what happened in one step.
The form opens with **Done on** set to today and you as the person who did it.
Where it was done, the item's fields (a lot number, a tag, a dose) and **Notes**.
The item is recorded as done. If it repeats, a line reads "Done. Next one due" with the date.
A vaccine, treatment, exam or procedure already recorded can be corrected with **Edit** on its row: the dates, its fields and its notes.
## Deleting a record
The bin icon on a row deletes that record straight away, without asking. It cannot be undone. A scheduled item's task is deleted with it.
## Weights
Weights are kept in grams and shown in your organization's unit, set under **Settings → Organization → General profile → Weight unit**. You can enter a weight in lb, kg, oz or g whatever that unit is.
### Logging a weight
On the record, press **Weight** under **Quick log**. The **Log a weight** form starts with the last reading, so a slip such as 55 for 5.5 stands out. Fill in **Weight**, **Unit** and **Recorded on**, and press **Save**.
A weight also comes from the intake form (noted "At intake") and from an exam.
### Weight history
The **Weight history** card shows the change **Since last reading** and **Since first reading**, a chart with the lightest and heaviest marked, and a table of every reading with its **Date**, **Weight** and **Change**. The bin icon on a row deletes that reading straight away.
## Due and overdue
An item is **due** when it has a due date and has not been done. On the record:
* its date reads **Next** while it is in the future;
* it reads **Due**, in amber, once the date is today or earlier. Overdue is more due, not less, so it stays until it is done;
* once done, the old date reads **was due**, and the next occurrence, if any, is its own row.
An item with a due date in the past that has been done is history, never overdue.
## The Medical due page
**Medical due** lists what is outstanding across every animal: the list a medical coordinator opens in the morning. Open it from the search palette by typing "Medical due" (see [Finding your way](/getting-started/finding-your-way)).
The numbers at the top count **Overdue**, **Due today**, and the items due in the **Next 30 days**. Below them, the items are grouped:
| Group | What is in it |
| ------------- | ------------------------------------------------------------------ |
| **Overdue** | Due before today and not done. Each says how many days late it is. |
| **Due today** | Due today and not done. |
| **Coming up** | Due within the window you are looking at. |
Each line shows the kind of record, its name, the animal and the due date. Press the animal's name to open its record and mark the item done there.
* **Looking ahead** sets the window: 7, 30 or 90 days. It starts at 30.
* **Kind** narrows the list to one kind of record, such as Vaccination or Treatment.
* **Species** narrows it to one species.
* **Views** saves the filters you use most, as on the [Animals list](/animals/list#saved-views).
## Adding a record to many animals
To give the same vaccine to a litter, or record one test for every cat in a room, select the animals on the [Animals list](/animals/list#selecting-animals) and press **Add medical record…**. It takes at most 100 animals at a time.
The **Add a medical record** panel asks once for what is the same for every animal, and has a table with a row for each animal for what differs.
**Kind** is Vaccine, Test, Treatment or Procedure. Then choose the item from your catalogue, or **Something else…** and a **Name**.
Choose whether it has already happened, with its date, or **Schedule it**. For one already given you can set **Next due**, or **Every** and **Unit**, exactly as on a single vaccine.
**Our own clinic**, or the practice and the vet.
Under **Different for each animal**, ticked fields get a column in the table; the rest are asked once, under **The same for all of them**. A lot number and a rabies tag start ticked, as do a test's result and findings and a treatment's amount.
One row per animal, with a **Notes** column. **Same for all** under a column heading copies the first animal's value to every row.
Press **Add to N animals**, or **Schedule for N animals**.
Every animal's record is checked before any is saved. If one is refused, nothing is added, and the message names the animals and why. A note for one animal is added to the shared note, not in place of it.
The panel does not ask whether a procedure is a spay or neuter; your catalogue decides that.