The Clinic Records Recorder ensures that all cats are accounted for before they leave the clinic, keeps track of all veterinarians and veterinary students who participate in the clinic, documents the vaccination status of each cat, verifies information on the Medical Record, Veterinary Examination Form, and Rabies Certificate, completes the treatment summary at the bottom of the Rabies Certificate, attaches To Go Home instructions to the Rabies Certificate/Surgery Recovery Instructions, files the completed forms, maintains a record of any problem that occurs during the clinic, completes the Clinic Report and submits all records and reports at the conclusion of the clinic. No rabies vaccination is required for this position.
- Visually monitor the cats closely. If the cat is moving, blinking or licking, then it is recovering normally. If the cat is fully sedated, watch the chest for movement. Breathing can be very shallow and difficult to see. A normal respiratory rate is 6 or more breaths per minute. If breathing is less frequent or isn’t visible at all, alert the Medications Technician to do a hands-on assessment immediately.
- All cats must be accounted for in the Clinic Cat Log (alive or deceased) before they leave the clinic surgery area.
Clinic Records Recorder Instructions
Cats admitted for vaccine boosters are brought to the Clinic Records Station after vaccination.
Collect all plastic sleeves and alert tags.
Confirm that the cat identification number on the Medical Record matches the Rabies Certificate and the Paw Tag.
Transfer the following information from each cat’s Medical Record/Veterinary Examination Form to the Clinic Cat Log, sign and date:
- Gender and color of cat.
- Cat’s surgical status, i.e. pregnant, lactating, in heat, kitten, cryptorchid male.
- Number of fetuses, if pregnant.
- Name of the DVM or veterinary student who performed the surgery.
- Location of the spay site, flank or midline. Double-check by checking the cat’s flank.
- Fluids or other post-surgery treatment ordered.
- Other observations or complications.
Record the names of each clinic veterinarian and veterinary student (DVM, spay veterinary student, and neuter veterinary student) who participates in the Clinic Veterinarian Log, sign and date:
- Note the names of the spay and neuter veterinary student supervisors on the Clinic Veterinarian Log
- Update the list as needed throughout the duration of the clinic.
Review the Medical Records, Veterinary Examination Forms, and Rabies Certificates for completeness. These documents serve as a legal record of each cat’s treatment at the clinic:
- Verify that fluids ordered and additional medications ordered have been transferred from the Veterinary Examination Form to the Medical Record.
- Transcribe special procedures (fluids, extra antibiotics, wound care, etc) and caregiver instructions from the Veterinary Examination Form and the Medical Record to the treatment summary at the bottom of the Rabies Certificate so the caregiver has a complete understanding of their cat’s condition and care.
- Review the Veterinary Examination Form for To Go Home orders requested by the DVM.
- Separate the 2-part Rabies Certificate, once it is completed.
- Staple TGH order slips to the caregiver’s original copy of the Rabies Certificate/Surgery Recovery Instructions being sent home with the cat at the Discharge Station.
- File the completed Medical Records and duplicate copy of the Rabies Certificates in numerical order.
- Deliver the original Rabies Certificate/Surgery Recovery Instructions with any TGH orders to the Discharge Station.
Sort all tags that have been removed from cats. Remove all masking tape from the back of the red “Medical Alert” tags and affix new masking tape so that the tags are ready for the next clinic.
Record any problem that occurs, no matter how trivial, in the Clinic Incident Log:
- Enter the Cat ID # and the name of the person who reported the incident.
- Describe the incident and Operation Catnip’s response.
- Sign and date the log.
Note: The Clinic Incident Log is required by the State Veterinary Board and is also used internally to improve future clinics and to ensure clinic safety.
Complete the Clinic Report, when the clinic has concluded:
- Enter the number of veterinarians, volunteers and cats.
- Record the start time of the first surgery and end time of the last surgery
- Record the total hours of surgery.
- Note the time when discharge concludes.
- Sign and date the report.
- Ask the Clinic Supervisor to complete end times if they occur after the Clinic Records Recorder leaves for the day.
Note: The Clinic Report is used internally to improve future clinics and to ensure clinic safety.
All Station Images
Station Closing and Cleanup
When the clinic is concluded:
- Inventory the remaining supplies and repack the supply kit.
- Return the kit, station instructions and any remaining items to storage.
- Clean the area and dispose of all trash.
- Wash all tables, including the central trough, and wipe down the entire base of the table.
- Remove the tape from the underside of the table.
- Wipe as much of the overhead surgery lamp as can be reached,
- Sweep or vacuum and mop the floor.