When we talk about veterinary software, it’s easy to get lost in “this tab does this, that button does that” discussions. But a patient’s visit doesn’t happen one software feature at a time. They don’t move through “the vitals module” and “the estimate module”. They move through a receptionist, a nurse, a veterinarian, a treatment team, and finally, discharge.
So in a recent Instinct Academy webinar, I set out to do something different. Instead of walking through Instinct EMR area by area, I followed a single patient from the first phone call all the way to discharge and showed how every member of the team contributes to the same record along the way.
Read on to see how Lucille’s visit unfolded. She’s a seven-year-old spayed Labrador whose owner, Sarah, called because she’d been vomiting overnight, skipped breakfast, and seemed unusually tired.
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Scheduling & Check-In Start the Patient Record
Lucille’s visit began the moment Sarah called. From the appointment calendar—the practice’s scheduling hub—our receptionist could see provider availability, pick an appropriate time, and enter the reason for the visit. Because Lucille was already a patient, we searched for her and added her to the schedule.
If she hadn’t been in the system, we could have registered a new patient right inside the appointment. And for a critical emergency, rapid registration lets you enter only the minimum information needed to get a patient into the system and start treatment, with the rest filled in later.
When Sarah arrived, we checked Lucille in (which didn’t take long). At check-in, we assigned her veterinarian, set her ward and location, and flagged any patient or visit alerts the team needed to know about. At that point, Lucille became an active patient that the clinical team could document and manage.
Capturing Vitals That Build a Trend
As the veterinary nurse, I brought Lucille into an exam room for her initial assessment. She was quiet but responsive, her heart rate was mildly elevated, and she seemed a little dehydrated. Under the vitals tab, I recorded her baseline: weight first (there’s a built-in calculator if you need to convert pounds to kilograms), then the rest of her intake vitals.
I love the way Instinct EMR handles this next part: Every additional set of vitals recorded during her stay is stored in the same place, so the team can see trends over time. For a hospitalized patient, that’s especially important. We’re rarely interested in a single temperature or one heart rate reading. We want to know whether they’re improving, if something’s changing, or if there’s a trend we need to act on.
Read: How to Help Your Team Succeed With Instinct
Read: How Multi-Doctor Veterinary Practices Can Support More Consistent Care
Charting That Saves Automatically & Works in Real Time
When the veterinarian stepped in to examine Lucille, documentation happened in the chart tab using the appropriate template. In this case, it was an initial exam, but your practice can build templates specific to your workflows.
Rather than re-typing the vitals I’d just captured, the veterinarian used snippets, a quick way to pull commonly used information straight into the documentation. Snippets can bring in patient details, intake vitals, treatments, prescriptions, and other frequently used text. Nobody has to retype what already exists in the record.
Two things make charting low-stress here:
- First, charts save automatically as you work, so there’s no save button to forget.
- Second, multiple team members can contribute to the same patient chart simultaneously. The veterinarian can document the exam while the nurse updates something else, and nobody gets locked out or overwrites anyone else’s work.
Estimates & Treatment Plans From Reusable Templates
After examining Lucille, the veterinarian was concerned about dehydration and wanted blood work and possible radiographs. On the estimate tab, you can enter every line item from scratch, but you don’t have to. We started from an estimate template (mine is a GI workup) that already included the exam, blood work, radiographs, IV catheter placement, fluids, and estimated medications, then adjusted it to Lucille’s specific needs.
Templates are one of the best ways to maintain consistency in your practice while still allowing each clinician to tailor the plan to the patient in front of them. Once the estimate looked right, it was ready to be approved and moved forward.
Read: Why Veterinary Hospitals Are Leaving Paper Treatment Sheets Behind
Read: Find the Right Patient Information Faster With Instinct EMR
One Record From Diagnostics Through Discharge
From there, Lucille’s approved plan flowed into her treatment sheet, where the team could order diagnostics, track fluids, and manage her medications through hospitalization, all tied to the same visit and visible to everyone caring for her. When it was time to send her home, discharge and invoicing pulled from that same record, so the paperwork reflected the care that actually happened.
Because scheduling, vitals, charting, estimates, treatment, and discharge all live in one connected visit, information doesn’t get re-entered, lost between shifts, or trapped in one person’s notes. The receptionist, the nurse, and the veterinarian were each doing their own job, but they were all building the same story of Lucille’s care.
A Few Answers From the Q&A
The webinar sparked great questions and a few came up often enough to share:
Can I use Instinct EMR on an iPad?
Many practices do, often with a keyboard attached. There isn’t a dedicated iPad app yet, but you can sign in with your credentials and use Instinct EMR on the device. Clients can type their name to capture an electronic signature. If you hit a snag setting it up, reach out to us at [email protected].
Can I customize chart templates?
Absolutely. Chart templates are built and edited in your admin section, and Instinct EMR’s chart builder is highly customizable. If you’re migrating from another PIMS, your adoption specialist or Customer Success Manager can help make your charts feel close to what you’re used to.
A patient was checked out too early. Can I reopen the visit?
If it’s within 24 hours, yes. Reopen the visit (or check the patient back in), and it merges cleanly. After that window, you’d typically use a standalone invoice, though keep in mind that it won’t route to the treatment sheet or generate lab work requisitions the same way.
Do vaccine reminders get satisfied from an estimate?
Send vaccines to the treatment sheet and complete them there. That’s what satisfies the existing reminder, generates the next one, and lets you record the lot number, expiration, and tag number. An item that only hits the invoice can create issues beyond the reminder itself.
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