Vet AI Scribe for Telemedicine

Record the video call and get a SOAP note built for a patient who isn't on your table: what the owner reported, what you could see on camera, what you couldn't examine, and the plan.

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What PawfectNotes Does for Telemedicine

Telemedicine – SOAP
A library template designed for appointments where the patient isn't in the clinic. The objective section keeps to what you saw on video and what the owner reported, and notes what wasn't examined.
Record the consult
Record on your phone beside the screen while you talk, or dictate a summary straight after the call. Use whichever video platform you already use.
A summary for the client
Communication – Visit / Discharge Summary turns the same recording into a plain-language summary and instructions you can send after the call.
Phone calls too
Call Summary and Communication – Phone / In-Person record client calls for the patient history, from a quick question to a long conversation. With Phone Calls on UnlimitedNotes, the callback itself writes the Call Summary.

Ready-made templates in the PawfectNotes library

Telemedicine – SOAP
Communication – Visit / Discharge Summary
Communication – Phone / In-Person
Call Summary
SOAP – Recheck Exams

Choose one in Templates before you record, or build your own.

Example Medical Records

Practice types & roles

Mobile Vet Relief Vets Telemedicine Urgent Care Mixed Animal & Rural Practice Referral & Specialty Hospitals High-Volume Spay/Neuter Corporate & Multi-Site Groups Veterinary Technicians & Nurses Veterinary Students & New Grads

Telemedicine

Pepper

Wednesday, October 21, 2026 at 6:45 PM

Telemedicine — video recheck, 9 days after mass removal

Subjective

Chief Complaint

Scheduled video recheck 9 days after removal of a 2 cm subcutaneous mass from the left flank on October 12.

History

9-year-old spayed female Shih Tzu; existing patient, examined in clinic on October 6.
Histopathology received October 16: lipoma, completely excised.
Eating and drinking normally; energy back to normal since day 3.
Finished meloxicam on October 15 as directed.
Wears the cone overnight; owner takes it off under supervision during the day. Licked at the incision once on day 7 and was stopped.
No vomiting, diarrhea or lethargy.

Objective

Video consult with the patient at home. Findings are from video observation and the owner's report; no hands-on examination was possible.

Observed on Video

Bright and alert; walking normally and jumping onto the sofa without hesitation.
Incision, left flank, approximately 4 cm: Skin edges apposed along the full length with no gaping. Mild pink color at the cranial end. No visible swelling or discharge.
Owner pressed gently beside the incision with no pain response.
Buried intradermal sutures; no skin sutures to remove.

Owner-Reported

No odor from the incision.
Resting breathing rate counted by the owner on camera: 20 breaths/min.

Not Assessed

Temperature, heart rate, body weight, and palpation of the incision for heat or fluid.

Assessment

Healing surgical incision, left flank — no sign of dehiscence or infection on video.
Lipoma, completely excised — no further treatment needed for this mass.

Plan

Cone can come off from day 14 (Monday, October 26) if there is no more licking.
Lead walks only until October 26, then back to normal activity.
No bathing until October 26.
Owner to email a photo of the incision on October 26.
In-clinic exam needed if: swelling, discharge, gaping, spreading redness, or licking that can't be stopped.
Next routine visit: annual exam due in February 2027.

Client Communication:
Went through the histopathology result: the mass was a lipoma, a benign fatty growth, and it was removed completely. Explained that a video check can show that the skin edges are healing but cannot pick up heat or fluid under the skin, so any swelling or discharge means she needs to be seen in person. Owner comfortable with the plan and will send the photo next week.

— Dr. Simone Achebe, DVM

Telemedicine FAQ

Does PawfectNotes run the video call?

No. Keep using your telemedicine or video platform; PawfectNotes writes the note.

How does the note handle what I couldn't examine?

The Telemedicine – SOAP template is designed for appointments where the patient isn't in the clinic, so the objective section is limited to what you observed and what the owner reported or measured. Read it through before it goes in the record.

Can I treat a patient over video?

That depends on where you practise. Rules on telemedicine and on establishing a veterinarian–client–patient relationship remotely differ between states and countries, so check your licensing board's guidance. PawfectNotes documents the consult; it doesn't decide what can be done remotely.

Should I tell the client the call is recorded?

Yes. Recording laws vary, and some require everyone on the call to agree. Our free recording laws lookup and consent form help.