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Record Patient History


Medical Notes are called "Clinical Records" in EzyVet. 

In Cornerstone, Medical Notes are combined into a single page. Charges and billing are handled separately.

In EzyVet, Medical Notes are broken into individual sections. Charges and billing are added as the notes are recorded.

"Case Owners" are assigned by appointment. This designates which vet is overseeing the appointment and automatically assigns billing and medical records to this doctor. Always verify the "Case Owner" is accurate when recording notes/billing.

All charges should be added to the "Treatments/Procedures" section of a Clinical Record (except medications).

History can be recorded by an ERA, a technician, or a doctor. A single history document can be edited by each person or multiple history documents can be added to a single Clinical Record (Medical Note). Always use a template when adding a patient's history!


(Blue) Adding History

  • Selecting the "+" to the left of History will open a pop-up window.

  • Initially, the contents of the window will be blank. Only the "Date & Time" and "Vet" boxes will auto-fill

  • The "Vet" box will autofill based on the current "Case Owner". The case owner is automatically assigned to whichever doctor the appointment is scheduled under. The "Case Owner" can be changed is needed (see section ___)

  • If the "Vet" box is incorrect, you must change the "Case Owner"


(Orange) Insert from Previous History

  • This can be used when a patient's history is unchanged. (This may be the case during a "LEPT2" appointment, for instance)

  • Click the magnifying glass to select which recent clinical record you wish to pull history from

  • This will copy and paste the history from your selected clinical record into your current clinical record


(Yellow) Always Use a Template!

  • Templates are an essential part of EzyVet Clinical Records (Medical Notes). These allow you to quickly fill out a patient's chart and will later be used to add appropriate charges.

  • For wellness exams, urgent care appointments, and office calls, you should select "Comprehensive History"


(Green) Recording History

  • EzyVet templates use a styling system called "Markdown". In unedited templates, this looks unusual but you can disregard the formatting. You do not need to understand Markdown to use EzyVet. You just need to use "tab" on your keyboard

  • Hit "tab" on your keyboard and a window will pop-up with questions contained within a dark blue box.

    • To choose an answer, you can either use your mouse to click the option you'd like or you can type the number associated with the answer you'd like to select

    • Example: Typing "2" will select "No" in for this question

  • Hit "tab" again to continue answering questions

  • Some questions require additional details which must be typed

    • Example: In this picture, selecting "3. Yes" will require details about the vomiting

    • Click the area next to "**Details:**" and free type your response

  • You can then continue using "Tab" to move through the questions


(Purple) Save the Patient's History

  • Selecting "Add" will save the history and close the window

  • Choosing "Add & Go To Physical Exam" with save the history and automatically bring up the Physical Exam window

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