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As a licensed veterinary technician, it's crucial to understand the importance of a veterinary medical record, which is a legal document owned by the veterinary hospital. Owners can request copies at any time. Key elements to include are the signalment, chief complaint, medical history, diagnostics, and treatment plan. Personal opinions about clients or informal observations—such as remarks about a client's demeanor or hygiene—should be excluded, as they can be used against you in legal cases. Only relevant medical information should be documented, emphasizing the need to refrain from personal judgments or diagnoses, as that role is reserved for veterinarians.
