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As a licensed veterinary technician, it's essential to understand the nature and content of a veterinary medical record. This record is a legal document owned by the veterinary hospital, but pet owners can request copies. Key components to include are the signalment, chief complaint, patient history, diagnostic results, and treatment plan. Personal opinions about the client or their pet, as well as any information that could be perceived as bias or personal judgment, should be omitted. Veterinary technicians cannot make diagnoses; it's crucial to maintain professionalism and objectivity to avoid legal implications.
