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Discussion on General Injury/Illness Report Sheet
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Member:
stek
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Posted on Thursday, Nov 6, 2008 - 12:17 pm:
Any time one of our horses has an injury or illness event, I like to write up a summary to put in their file for future reference. I thought it might be handy to have a blank form we could fill out instead, both for farm records and to provide info to the attending vet if one is called.
I am attaching what I have so far, if anyone can offer any comments or suggestions about what other info might be useful I'd appreciate your input.
Also Dr. O if you could suggest anything you would want to know from the perspective of the vet I would appreciate it too.
If anyone would like to use the checklist when it is done you are more than welcome.
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Member:
ajudson1
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Posted on Thursday, Nov 6, 2008 - 3:41 pm:
Nice idea Shannon. I used to have some pad I bought years ago where I kept track of things like that. Then I tried using a notebook so I could keep track of training too. Got too complicated so now I just use a calendar but I like the idea that you came up with, especially the symptoms to circle.
DrO. looking forward to your input?
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Member:
maggienm
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Posted on Thursday, Nov 6, 2008 - 10:43 pm:
Great idea.
I use a notebook to keep track of training, farrier, worming etc.
Will add some of your ideas as a check list of things to do or look for.
Thanks.
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Member:
quatro
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Posted on Friday, Nov 7, 2008 - 2:04 pm:
Shannon, that is a great idea. I might suggest adding Date of Last worming on the sheet, and what kind of wormer was used. In case it might be relevent
suz
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Moderator:
DrO
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Posted on Tuesday, Nov 11, 2008 - 7:44 am:
Guys I cannot read the document above as I do not have word and have some sort of Microsoft bug(?) that refuses to open it in Notepad or Wordpad. On top of that my WordPerfect inexplicably refuses to recognize the file to translate it. I have yet to be able to look at it.
DrO
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Member:
ajudson1
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Posted on Tuesday, Nov 11, 2008 - 8:08 am:
DrO,
I think there is a setting that you can change to choose how to open attachments like the one above. Unfortunately I don't remember how to do that, but maybe a HA member does and can help. I know I can never open attachments in notebook.
Or perhaps Shannon can upload it as an attachment, or copy and paste it here. I hope you get to see it, I am awaiting to hear your thoughts on her ideas.
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Member:
ajudson1
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Posted on Tuesday, Nov 11, 2008 - 8:12 am:
Pinecrest Horse Illness/Injury Event
Horse’s Name ____________________________________________________________
Owner’s Name___________________________________________________________
Date and Time Illness Presented _____________________________________________
Brief Description of Illness__________________________________________________
________________________________________________________________________
VITALS
Pulse ___________________________________________________________________
Respiration Rate __________________________________________________________
Temperature _____________________________________________________________
Mucous Membrane Color & Condition ________________________________________
Cap Refill Rate ___________________________________________________________
Gut Sounds ______________________________________________________________
CIRCUMSTANCES
Last Meal Eaten _______________________________________Time ______________
Last Turnout ____________________________________________ Alone / Group
How was horse found ______________________________________________________
________________________________________________________________________
Known Pre-existing Condition ______________________________________________
Medications Horse Receives ________________________________________________
Vaccinations Within last Year & Dates Given __________________________________
________________________________________________________________________
SYMPTOPMS PRESENT (circle all that apply)
Lack of Appetite Depression Pawing Lying Down Rolling Sweating
Pacing No Bowel Movements Diarrhea Abdominal Pain High Fever
No Gut Sounds Very Gassy Gut Sounds Sand in Manure Panting
Slime Coming out of Nose Neck Spasms Swollen Glands Snotty Nose
Coughing Sneezing Loud Respiration Dehydration Shivering/Shaking
Reluctant to Move Lame (RF LF RH LH) Open Wound (area: )
Swelling (area: ) Foreign Body (describe below)
Other Symptoms:_________________________________________________________
________________________________________________________________________
First Aid Treatment:_______________________________________________________
________________________________________________________________________
Vet called: Y / N Vet’s name _____________________________________________
Veterinary Visit: Y / N Date ______________________ (Attach report if available)
Diagnosis: ______________________________________________________________
Vet Treatment Recommended: ______________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
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Member:
ajudson1
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Posted on Tuesday, Nov 11, 2008 - 8:14 am:
I just copied it and pasted it. Hope it's all there. (surprised it worked, my computer is freezing up a lot lately!)
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Member:
ajudson1
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Posted on Tuesday, Nov 11, 2008 - 8:16 am:
Shannon,
I should have put your name on it before putting here, it is your idea! I apologize for not doing that.
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Member:
wgillmor
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Posted on Tuesday, Nov 11, 2008 - 9:07 am:
DrO,
Google Docs will open the file.
Wiley
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Member:
maggienm
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Posted on Tuesday, Nov 11, 2008 - 9:46 am:
Wiley, how do you do it that way?
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Member:
ajudson1
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Posted on Tuesday, Nov 11, 2008 - 10:11 am:
Wiley,
Could you explain how to open an attachment when I get notepad and get goobly gook? Same thing, with google docs?
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Member:
stek
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Posted on Tuesday, Nov 11, 2008 - 10:24 am:
Sorry for the trouble with the attachment, I have tried attaching as a pdf this time. Please let me know if you are able to open it, I could also attach as a text file if need be.
Thanks!
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Member:
wgillmor
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Posted on Tuesday, Nov 11, 2008 - 12:20 pm:
Google Docs:
1. Download the file to your computer.
2. Open a Google Account if you don't have one already:
a. Go to https://google.com.
b. Click on Sign in.
c. Click on create one for free on the left center down about three lines.
3. Go to https://docs.google.com.
4. Click on Upload next to New on the left of the tool bar.
5. Email me at wiley(dot)gillmor(at)gmail(dot)com to complain if you have a problem.
Wiley
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Member:
maggienm
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Posted on Tuesday, Nov 11, 2008 - 1:22 pm:
thank you, so do you give lessons?
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Member:
wgillmor
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Posted on Tuesday, Nov 11, 2008 - 4:53 pm:
You're welcome.
You don't want lessons on anything from me. I tried teaching as a career and I'm only useful to people that can figure it out themselves.
Wiley
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Moderator:
DrO
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Posted on Wednesday, Nov 12, 2008 - 8:23 am:
Seems like a very complete form. It I were going to use such a form the one thing I would change is that there are 2 clinical assessments under symptoms: abdominal pain and dehydration. You already include most of the signs of ab pain so DrOp the assessment which requires a diagnosis of the cause of the colic which may not be abdominal. You can include signs of dehydration (possibly in the vital sign section) but remove the assessment. By removing premature assessments you may avoid the problem of incorrect assessment and inappropriate treatment.
DrO
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Member:
stek
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Posted on Wednesday, Nov 12, 2008 - 3:43 pm:
Thanks all for your help and input, and thanks Dr. O for reviewing. You make a good point that 'abdominal pain' and 'dehydration' are more diagnosis than symptom! I started out with symptoms such as 'colic, founder, choke, tying up' etc, then realized I was very much jumping the gun.
Keeping it descriptive will keep my personal tendency to rush to judgment in check, and make it much easier for someone with less experience to accurately describe what they are seeing.
Thanks again!
-Shannon
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Moderator:
DrO
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Posted on Thursday, Nov 13, 2008 - 9:09 am:
I caught another one: "Lack of Appetite". This too is a judgement but misrepresents a horse that is hungry but does not eat because the food smells or tastes funny. Better is the non-judgemental observation of: "Not Eating".
Your instincts on importance of the difference between a observation and a judgement are good Shannon. Medical records are often thought of in term of the acronym SOAP:
Subjective findings: symptoms that require a value judgement: example: "depression"
Objective findings: "repeatable measurements"
Appraisal: diagnosis or rule out list
Plan: what is the treatment and/or next diagnostic step
One should note that "history" does not figure in easily anywhere with SOAP and most often included first under "subjective". Using the SOAP acronym can help a clinician develop logical diagnostic and treatment plans to treat more complicated clinical cases and I "SOAP" all requests for clinical information but must filter this through the idea that often the person reporting to me does not have the experience or vocabulary to accurately express what is going on.
DrO
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Member:
stek
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Posted on Thursday, Nov 13, 2008 - 4:40 pm:
Thanks again Dr. O, that is a good acronym to remember. It seems to me that when you know a horse well, the first symptoms you notice are the subjective ones, a horse that just doesn't look 'right'. The trick as you point out is to nail it down to objective findings to diagnose.
99 times out of 100, there is no such thing as a horse that is just depressed, or just not hungry for dinner. There is always an underlying cause.
I have altered the checklist a bit, added a new item (standing camped out or under) and 'generified' it so anyone can use it. HA members, please feel free to use/share as you see fit.
Thanks again for providing a great online community!
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Member:
ajudson1
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Posted on Friday, Nov 14, 2008 - 10:45 am:
Thanks Shannon for providing that, and thanks DrO for tweaking the checklist. I plan on printing some copies for the tack room, and putting plastic sheets over them so they are readily availbale if a horse becomes ill or hurt and I am not there.
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Injury/Illness Info Sheet
Horse Illness Event Sheet