Associate Doctor

No drill/quiz needed for “Cryoprobe”. This procedure is a reference.

[51]

1027 - Declaw Principles and Guidelines

Results Statement: To assure any declaws that are performed are best for that individual
cat. The decision to declaw a cat and the surgery itself should benefit
the patient








Primary Responsible Position: Veterinarians

Participating Positions: Techs and TA’s
Our General Position: As a general rule we discourage declaws unless the alternatives and
risks of NOT declawing is worse for the cat. We work as a partner with
the client in making and informed decision that both the client and
veterinarian can both be comfortable in knowing it was the right
decision.

Client Communication: Clients need to be informed of the following before they decide:

 Declawed cats have higher risks for chronic pain, inappropriate
urination/deification, and biting among other. These risks are
approximately 3-9X more likely than non-declawed cats.
 In some cases, declaws are helpful to:
o The Patient - more loved, less risk of adoption
o Other Pets - might protect other pets
o The Family - more pleased with cats in the house
 Declaws performed at our hospital are much safer and comfortable
than average because:
o We hospitalize for two nights after declaws (lowers pain
and complications)
o We use extensive pain control measures including local
blocks, pre-op pain meds, post-op pain meds, etc.
o We ideally attempt to schedule declaw surgeries with the
same surgical doctor also present the next day for post-op
care and bandage removal.


No Quiz/Drill needed for this procedure. Procedure is for reference only.






[52]

[53]

1028 – Dermatophyte Cultures


1) Use Sab-Duet DTM
 Plates should be cultured in the dark for 14-21 days
 Plates should be checked daily for color change and growth to determine if growth seen
is causing the color change (DTM)
 Dermatophyte growth should be white or buff in color, but never darkly pigmented
colonies
 A color change to red should be seen in advance of colony growth (DTM)
 Sabouraud’s agar can more easily grow diagnostic macroconidia


2) Tape prep
 Gently touch a clear piece of scotch tape to the colony
 Place 1-2 drops of lactophenol blue on microscope slide
 Place scotch tape on microscope slide over lactophenol blue
 It may help in visualization of macroconidia if you place another drop of lactophenol
blue on top of the scotch tape and then cover with a cover slip


3) Tips for collecting samples
 Cut back long hairs to prevent contamination from the hair tips
 Pat area with isopropyl alcohol impregnated gauze and allow to dry (prevents bacterial
contamination)
 Pluck hairs from around the periphery of the lesion
 Place scales, crusts, and hairs collected directly onto the culture
 McKenzie toothbrush technique (for cats with no lesions present)
o Use a sterile toothbrush to stroke cat all over
o Take hair/scales off the toothbrush and put on the DTM culture



No Drill/Quiz needed for this procedure on a routine basis. This procedure is a reference.


















[54]

1030 – Disagreements About Doctor Production

Result Statement: Cases among various doctors are assigned and booked based on two
priorities (in this order):
1. Patient care
2. Client Service

Many cases require good judgments based on the above, not on the
doctor’s paycheck. These cases require good communication and
resolution of conflicts between those two doctors using that good
judgment, not be involving others into that conflict.

What WILL happen:
1. Doctors will settle disputes over production and “doctor of record” BETWEEN THEMSELVES
using current procedures and good judgment as the guide.
2. Judgments over appropriate doctor are made based on bet patient care FIRST and client service
SECOND. Doctor preference or income in NOT part of the judgment.
3. Disputes that CANNOT BE SOLVED WITH THE TWO DOCTORS themselves will be brought to vet
administrator or ED. The VA or ED will choose the doctor getting production on that case
IMMEDIATELY and RANDOMLY without any further discussion.
4. VA and ED will create procedures and a hospital environment that creates fairness and
opportunities for reasonable judgment.
5. If a doctor feels another doctor is not following procedures, unethical, and/or putting
production ahead of patient care or client service:
a. That doctor reports that information to the ED IN WRITING (e-mail or hard copy private
letter). If the above is accurate the owner or ED will prevent it in by whatever means
necessary.

What WILL NOT happen:
1. Clients choosing doctors for EMERGENCIES. The patient goes to first or best available doctor for
that patient at that time.
2. Clients getting emergencies handled during open hours by doctors NOT in the building. When
we are open and a client has an EMERGENCY, they call the HOSPITAL or come in immediately or
both.
3. Doctors will not be reviewing appointments of other doctors or discussing booking with staff for
the purposes of their individual production. The staff will be trained to book patients based on
that patient’s best care or that client’s preference. If they don’t, they will be corrected first,
then terminated.

Drill/Quiz for “Disagreements About Doctor Production”:

1. In your own words describe what should happen when disagreements arise?
2. What are the 2 only priorities in making decisions?
3. Do clients get to pick a doctor when they have an emergency?
4. What will NOT happen with these disagreements?




[55]

1032 – Drop-Offs

Results Statement: To provide great client service by offering drop-off services for
their pets and assure pets are ready to go home by 5pm.






Primary Responsible Position: Associate DVM’s

DROP-OFF VS. OWNER WAITS:
 For most any in-house testing that takes more than 10
minutes (radiographs, general health profiles, etc.) to
complete we recommend that the owner drop the animal
off.
 We can call when the results are in and to discuss treatment
recommendations.
 We usually always ask the owners to wait for the simple
skin scrapings, ear cytology’s, snap tests, etc.
 We prefer to sedate animals for deep ear flushes, rads on a
very painful or excitable patients, etc. Owner’s almost
always drop-off and we call when ready.
 “Drop-offs” can often be better accepted if referred to as
“No-charge pet sitting”.



































[56]

DOCTOR RESPONSIBLE FOR “DROP-OFF” AND ICU PATIENTS:
 On the TYPICAL routine doctor schedule the doctor responsible for drop offs are as follows
(variations in vacation/CE time off can change this schedule using good judgement):
o Monday – Dr. Kelley
o Tuesday – Dr. Kelley
o Wednesday – Dr. Cohen
o Thursday – Dr. Ryder
o Friday – Dr. Cohen - if not working: Dr. Ryder)
 Certain conditions can ALTER the doctor on the case based on the best patient care and client
service. Examples of these causes are:
o The listed doctor is not working that day or scheduled to come in at noon or after
o Best patient care:
 Rechecks that would be best on same doctor
 Sick or hurt animals needing faster care
o Best client service:
 Client requesting a certain doctor that IS AVAILABLE
 Client here to pick up pet early, mistake was made, etc.
 ULTRASOUNDS: they go under that the doctor that is HERE when it is completed. If the case is
being managed by ONE doctor it need to be SCHEDULED WHEN THAT DOCTOR IS HERE.
 PRE-OP LAB WITHOUT PRE-OP EXAMS: they go under the DOCTOR DOING the surgery. This
improves continuity of care and client service.
 If the drop-off doctor needs other doctor’s assistance in completing drop-off patients in a timely
manner they should communicate this to all other on-duty doctors.
 If the non-surgery doctor would like to help with the drop-off patients due to a large patient
load, free time available, etc. they should ask the primary surgery doctor which, if any, patients
they would like assistance with.

Exceptions to the above:
o If the surgery doctor is not scheduled until NOON the appointment doctor handles as
many drop-off patients as they can thoroughly handle.
o The FIRST AVAILABLE DOCTOR should handle critical drop-off patients or those in
significant pain, regardless of schedule.
o If the client has requested a specific doctor the patient can wait until that doctor is
working and available.
o If there are a large number of drop-offs or booked schedule (holiday boarders, etc.) all
doctors should use reasonable judgment and communication in helping each other with
cases.

















[57]

AFTER DROP-OFF EXAMS ARE DONE:
 on sick/hurt/non-routine pets the doctor calls the client with the treatment plan and cost. If it is
a very thorough treatment plan the doctor can delegate the discussion of price to a tech. The
plan must be discussed by the doctor prior. Either way all calls must be documented as a follow-
up.
 Same report card and release instructions as listed in “Report Cards and Release Instructions”.
o Report cards and discharges instructions are printed, put on clip board, and left in the
“Tech Release” box in the treatment room.



Drill/Quiz for “Drop-Offs”:

1. Which doctor is responsible for drop-offs on Tuesday for an example?
2. What if that doctor does not arrive until noon that day?
3. What if you are working at 8:30 AM and the drop-off doctor is in at 10 AM…and you notice a
drop-off that says vomiting 6 times this morning? Should you look at it or wait for the 10 AM
doctor so you don’t offend the drop-off doctor?
4. What do you do if that doctor has tons of drop-offs and may be getting behind?
5. After you complete your drop-off exams (as a group or one at a time) what do you do?
6. What time should routine drop-off patients be ready to go home?













































[58]

1032.005 – Ear Hematomas


Results Statement: To provide a standardized, safe way to surgically treat ear hematomas
in a way that is both cost effective and easiest for clients.

Primary Responsible Position: Veterinarians

Surgical Time: The procedure itself takes less than one minute.

Client Charges: Standard charges for sedation, analgesia, hematoma surgery, etc.

How to Treat:
1. Sedate the animal with simple sedation as a standard.
2. Prep the area as with any standard surgical prep (clip hair and
sterile scrub).
3. Standard non-sterile latex gloves are used. To minimize
contamination do not touch the portion of the teat cannula that is
inside the ear.
4. Make a very small stab incision in the most ventral and medial
portion of the hematoma.
5. Remove the teat cannula cap and discard to it remains open to
drain.
6. With very firm pressure (nearly stabbing action) insert a Dr. Larson’s
teat cannula into the stab incision
a. Teat cannulas do NOT need to be sterilized
b. Teat cannulas do NOT need to be sutured in place. The
barbs keep it in place.
7. Reverse the animal’s sedation appropriately.

Release Instructions: The teat cannula stays in place for 5-6 weeks.

How to Remove:
1. Sedate the animal with simple sedation.
2. Debride or manipulate the teat cannula out of the ear pinna
3. Leave the opening to heal by second intention.
4. Reverse the animal’s sedation appropriately


Reference Procedure Only. No Drill/Quiz Needed.













[59]

1032.01 – Ear Packing

Results Statement: To provide an efficient, safe, and effective way to treat ear infections
beyond the normal client-applied ointment at home.





Primary Responsible Position: Technicians.

Participating Positions: Veterinarians

What is Oti-Pak: Combination medication that delivers select medication to the inside of
the ear. It stays in the ear killing bacteria and yeast. It dries and
eventually falls out.
It is lanolin based and the Oti-Pak-E variant contains:
o Enrofloxacin 0.23%
o Ketoconazole 1%
o Triamcinolone Acetonide 0.1%
Dosage:
o ~ 3 cc per ear for dogs over 35 lbs
o ~ 1.5 cc per ear for dogs under 35 lbs
o ~ 0.5 cc per ear for cats

AVImark: Code – 51139 Oti-PAK E (per cc)


Reference Procedure. No need for drill/quiz.



























[60]

1032.1 - Emergencies

Results Statement: To assure all pets who need a doctor immediately (and clients who feel
their pets need to see a doctor immediately) get that service, are
charged appropriately, and satisfied. To assure cases are properly
triaged if we have multiple emergencies in the same time frame.



What is an Emergency?: If the pet or the client needs a vet RIGHT NOW, it IS an emergency. It
does not matter whether we are fully booked, totally caught up, client
does not have money, gets euthanized, etc. It is an emergency.

When Do We See Them? ANYTIME WE ARE OPEN.

When Client Calls Ahead: Receptionists as much information about the pet and relay the
information to the treatment staff.

What if a doctor is not here? See procedure 19040 Emergencies with No Doctor.


Three Types of Emergencies:

True: Pet is critical and client knows it.






Pet Only: Pet is critical but client does NOT KNOW IT.












Client Only: Client FEELS pet is critical although it is NOT









[61]

How Each Type is Treated: All three types are treated exactly the same. We get a doctor
immediately! See the next page.

Steps to take for Each Type:


True Emergency: Pet is critical and client knows it. This is the type that is the most common.

1. Page overhead “Technician to reception STAT!” Technician will get the pet to the
doctor IMMEDIATELY
2. Client stays in the building. THE CLIENT DOES NOT LEAVE UNTIL THEY HAVE
SPOKEN TO THE DOCTOR. We need to make life and death decisions NOW. A
doctor needs to speak to that person in person before they leave!
3. Client signs a full treatment plan recommended by doctor and pays the FULL
AMOUNT of treatment plan as a deposit BEFORE leaving. Certain exceptions to this
deposit will be made by doctors and management only.

Pet Only Emergency: Pet is critical although the client does NOT KNOW IT.

1. IF IT IS AN OBVIOUS EMERGENCY (NOT BREATHING, EXCESSIVE BLEEDING, ETC.):
Page overhead “Technician to reception STAT!”…or…Technician will get the pet to
the doctor IMMEDIATELY.
2. IF IT IS NOT AN OBVIOUS EMERGENCY: Get a technician to determine if the patient
should be treated as an emergency. Do this by paging “technician triage”.
3. If it should be treated as an emergency, client will need to be informed that the
animal is having an emergency and will need to see a doctor IMMEDIATELY! The
emergency exam fee applies because we will not let their pet suffer and go
without immediate treatment.
4. Client stays in the building. THE CLIENT DOES NOT LEAVE UNTIL THEY HAVE
SPOKEN TO THE DOCTOR. We need to make life and death decisions NOW. A
doctor needs to speak to that person in person before they leave!
5. Client signs a full treatment plan recommended by doctor and pays the FULL
AMOUNT of treatment plan as a deposit BEFORE leaving. Certain exceptions to this
deposit will be made by doctors and management only.

Client Only: Client FEELS pet is critical although it is not

1. Page overhead “Technician to reception STAT!” Technician will get the pet to the
doctor IMMEDIATELY
2. Client stays in the building. THE CLIENT DOES NOT LEAVE UNTIL THEY HAVE
SPOKEN TO THE DOCTOR. We need to make life and death decisions NOW. A
doctor needs to speak to that person in person before they leave!

[62]

3. Client signs a full treatment plan recommended by doctor and pays the FULL
AMOUNT of treatment plan as a deposit BEFORE leaving. Certain exceptions to this
deposit will be made by doctors and management only.


Which Doctor? Below is a basic guideline of which doctor would be best to see the
individual pet emergency. It is a form of triaging of which doctor should
handle the case.

GUIDELINE: In numerical order starting with the MOST likely doctor to
take the case to the least likely doctor. For example: If one doctor is on
the phone (#4) and the other is in an exam room (#5), the doctor on the
phone politely hangs up and takes the case.

1. Doctor completely caught up and NOT leaving for lunch or end-of-
shift within 30 minutes.
2. Doctor only working on medical records
3. Doctor standing in treatment room
4. Doctor is on the phone.
5. Doctor is in an exam room.
6. Doctor is in surgery.

NOTE: It is understood that there can be exceptions using good
judgment. We always keep the priorities in line with:
1. Pets’ health staying the highest priority and
2. Client service staying #2.
3. Doctor’s convenience or preference is a DISTANT third

Emerg. Surgeries when Open:
Reschedule other clients?
 Whenever emergency surgery will delay other clients, receptionists
must be informed call to re-schedule those appointments.
 Those receptionists will explain to the reason for the re-scheduling or
delays.
 It’s easier to re-schedule existing clients than new clients. You will want
to be more creative and accommodating to get new clients seen.
 We can offer clients incentives such as free bath or NT as a thank you.

Block-Offs:
 Block off time in the schedule to allow the DVM and their team to
devote themselves to the patient needing the surgery.











[63]

How we handle the other appointments:

o ALL OTHERS WAIT: With emergencies all other appointments and surgeries all go “on-
hold”. We do NOT have enough scheduled support staff to be handling emergencies
AND regular appointments at the same time for one doctor.
o WATING CLIENTS ARE GIVEN OPTIONS: The staff joins to together to inform ALL waiting
client and upcoming appointments of this delay. The client is given options.
o UPCOMING CLIENTS ARE CALLED: ONLY Receptionists, Department Heads, or Execs (not
techs or TA’s) will use good judgment to call upcoming appointments that are likely to
be delayed. The doctor will give estimate of how long the delay may be. The doctor will
over-estimate. Clients will be offered options (longer wait, reschedule for later,
reschedule for another day if NOT sick or injured).
 Note: Good judgment on these calls are critical. For example, if a doctor is in
emergency surgery we may be forced to reschedule a vaccine appointment for
another day. An itchy dog appointment may need to be seen today regardless
because the pet is uncomfortable or painful.



















































[64]

1034 – Emergencies when Doctor is Out

Results Statement: To properly handle an emergency with no doctor in the building
in a way that is best for THAT PATIENT, not what is best for us.















Primary Responsible Position: Technician

Overview: Occasionally clients will walk in with emergency cases when we
do not have a doctor in the building. This typically would
happen before 8 AM on weekdays or during lunch hours. This
procedure gives you the exact steps to take in order to get the
patient cared for as soon as possible.

See “Emergencies” procedure for definition and three types of
emergencies. This procedure applies to all three types of
emergencies. In most emergencies it is safe to wait the 10-15
minutes on our doctors while our techs do what the doctors
advise by phone.

Doctors scheduled for the same day will be available by phone before 8 AM for any walk-in
emergencies. It is understood that the doctor may be too far away to get here in 10-15
minutes. There may be times as doctors when we have to advise our technicians on how to
care for the pet until we get here (catheter, oxygen, valium, etc).

On lunches with no other doctor in the building is critical that the doctors be available to
answer their phone and cut lunch short to return to the hospital to treat any emergencies. The
primary doctor that would be responsible for this is the doctor next scheduled for
appointments but any doctor working that day be need to be called.

Overall all doctors scheduled for the day will use their best judgment on these emergencies
with one priority in mind: How can the pet and client get the best care in the right amount of
time?

[65]

For LAY STAFF: What to do on emergencies with NO DOCTOR:

1. Before 8 AM:
a. Page a technician to come take the patient to the back and monitor.
b. Immediately call the appointment doctor that is scheduled to arrive at 8AM on that
doctor’s cell phone number.
i. If not reached leave a voice mail.
ii. Call the surgery doctor or any other doctor scheduled for that same day.
iii. The doctor WILL call back before they get here.
c. Communicate very clearly with the client on the following:
i. We do not have a doctor in the building at this time but are calling our doctors
to get an estimated time they can be here AND anything that can be done for
their as the doctor directs us by phone.
ii. If we are unable to immediately reach our doctors the client has the option of
taking them directly to the emergency clinic where they are open with doctors
on staff. They can also wait until our doctor calls back.

2. On lunch or during doctor meetings out of office:
a. Same as above but:
i. Call the doctor who is next scheduled for appointments. That doctor WILL have
his/her phone available and cut their lunch short to return here and treat the
patient.
ii. Keep in mind that the doctor may not be able to immediately answer their
phone but should be able to call back within less than 5 minutes.
iii. Tell the client what you are calling the doctor to get them back to the clinic
ASAP.
iv. The emergency clinic is NOT open but the client always have the option of going
to the closest clinic to us which is Stonebriar Vet 1 ½ miles south on Legacy. We
want whatever is best for the patient, regardless of which clinic.


Drill/Quiz on “Emergencies with NO DOCTOR”:
1. Why do we have the procedure? What might happen if we did not?
2. Explain what YOU would do and say in YOUR position when this happens:
a. Before 8 AM
b. During doctor lunches or doctor meetings held outside the building











[66]

1035 - Exam and Consult Efficiency

Results Statement: To assure both the highest quality medicine, highest quality
client service, and on-time appointments.

Doctors do this by efficiently performing exams, consults, and
verbal treatment plans in under 7 minutes (90% of the time).
This will ensure both our clients and staff are happier…..and
more compliant.

Primary Responsible Position: Doctors

Participating Positions: Techs and Tech Assistants

Why Be Fast? In general clients never want to be at the vet appointment for
30 minutes or more. Usually they would prefer 15 minutes as
long as their pet gets better, has illnesses prevented, and we
answer all their questions. If you are not efficient with these
times clients will wait longer…and be less happy…less
compliant.

Before Entering Exam Room: In 2-3 minutes read the appointment notes and the patient
record BEFORE you enter the room. Make a quick diagnostic or
treatment plan (in your head or in AVImark). This requires you
to show up to work at least 10 minutes before your
appointments start.

MOST IMPORTANT! Know what next step you plan to do
before entering the exam room!

You will need to have your diagnostic plan or treatment plan (if,
ideally, you already have diagnostics) READY TO GO before your
exam. You can easily change that plan if you find surprises on
your exam.

During the Exam (1-2 min): Take a history DURING your exam. Ask your standard few
questions (What’s going on? How long? EDUD abnormal?)

Examine the entire patient focusing on the important areas;
abdominal palpation, thyroid palp, lymph nodes, hydration
status, mucous membrane color, ears, heart/lung Aus. That is
where 99% of your exam will take place.

Focus on the MAIN problem and client concern. Don’t get
distracted by minor issues you may find on physical exam.
These extra things can all be treated, but the labs/diagnostics
are the most important part on these anyway.

[67]

After the Exam (1-2 min): Inform the client what you would like to do next and why,
WITHOUT prices (unless quoting the price range will save time
and/or get a better compliance).

Quickly use demo pieces; heart model, ear model, laminated
example lab results, hand-written piece of paper with list of
what you plan to do, etc. Include the labs or treatments for any
surprises you found during your exam.

Assure the client appears to be easily understand your plan and
WHY. It should easily make common sense to them. Address
any objections now, before they have prices.

Before you leave the exam room: “Do you have any other
questions for me? Great! (Tech name) will be back shortly with
(pet name)’s treatment plan. They will get him/her taken care
of. Thank you!”

Outside the Exam Room: 2 Minutes - Turn the case over to your technician by either:
1. Dictating your plan while your tech writes it down…or
2. Writing it down yourself.

This step MUST BE WRITTEN!! This will save you from
questions, errors, and interruptions later.

The fastest way to get this all written is by using a “travel
sheet”, “circle sheet” or “check sheet”.

5 minutes - Go complete your medical records while the techs
finish the labs, treatments, meds, etc. 90% of your records
should be able to easily be completed in less than 5 minutes
(see separate procedure).

Doctor Needed Later? If your techs need you to look at labs or need help with
something later they can find you. Ideally any of these should
only take you 1-2 minutes, 5 minutes if complicated.

Client Traps You? If you are in an exam room more than 5-7 minutes the techs
and TA’s are always allowed to interrupt or “save” you! This will
help you to shorten those lengthy conversations and keep you
on-time, without upsetting the clients.











[68]

Total Time: Doctors should be able to complete exams, consults, treatment
plan, and patient records in less than 15 minutes total 90% of
the time. If it is taking doctors longer, multiple negative
consequences will likely be happening:
 Appointments will be running late.
 Wait times will be longer (decreased client happiness and
compliance)
 Staff will be working past their scheduled shift (overtime,
burnout)
 Doctors will be working late catching up on records
(burnout, stress, lower production)
 Staff confusion, stress, and mistakes.
 Staff not wanting to book more appointments = lower
revenue = lower staff hours = more stress  viscous cycle!

Example Case 1:

You have a 15-year old cat with a history of weight loss in Room 2. You should know your next step
BEFORE you walk into the exam room. You will need to at least run bloodwork, and maybe radiographs.
Make this treatment plan in your head, or in AVImark if you have time. Your top 3 Differential Dx’s
should already be Diabetes, Chronic Renal Failure, and Hyperthyroidism, before you enter the exam
room.

Take a history as you are performing your physical exam. How long have they noticed the weight loss?
Anorexia? Vomiting? Diarrhea? Pu/Pd? In this case really focus on the important areas –Listen the
heart and lungs, of course, and examine the rest of the body.

Don’t focus on any other physical exam findings that you may find that are not important at this point,
i.e. otitis externa. You can easily get distracted from the main and most important problem – weight
loss – by wasting time on the otitis. It should be treated, but the labwork is the most important part of
this weight loss case. Once you have your main diagnosis, then talk about the otitis and treat that too.

After you have taken a history and perform a physical exam, talk to the owner about what diagnostics
(or treatment plan is needed) and get their approval without price (unless you know telling them the
price range will get a better result and save time). You should have a technician go over treatment plan
after you leave the exam room.

Once you have your diagnosis, then go over it briefly with the owner. If it is diabetes, talk to them about
change of diet, insulin therapy. Then have the technician go over the details. The explanation part
should take 1-2 minutes. The rest of the time should be taken care of by the technician.













[69]

Drill/Quiz for “Exam and Consult Efficiency”:
1. How long should it take a doctor to complete 90% of exams, consults, treatment plan, and
records? What happens if takes longer?
2. By role playing with your trainer acting as the client and tech go through a sick exam and an
annual exam and plan. Go through the steps/skills you would use to get to the point of turning
the case over to your tech. AVImark is not needed for any of these steps.
3. Get a pass only when you can complete the steps in #2 above in less than 7 minutes.




































































[70]

1036 – Exam Room Efficiency

Result Statement: To have EACH veterinarian see appointment in TWO exam rooms with
each appointment staggered by at least 10 minutes. To have support
staff properly scheduled and trained in their position so that we are
increasing quality patient care, client satisfaction and staff well-being.
We are doing this while being prepared to handle emergencies and
urgent care….keeping appointments on time at least 90% of the time.


Overview: Saturday & Sunday OPEN appointment slots are 40 minute each to allow
online and clinic scheduling while supporting Appointment Scheduling
Guidelines (19001 - Appointment Types, Lengths, and Rescheduling)


CRITICAL FACTOR: These three critical factors are true every day for all positions. They are
even more critical for exam room efficiency. If they are not followed

1. DON’T ABANDON YOUR POST!
2. HELP OTHERS…after you have handled your own post.
3. DO ONE THING AT A TIME, IN THE RIGHT ORDER:
In most every situation, we have specific positions to handle it. If
you have two responsibilities at the same time know what to do
first! Get help if someone else is caught up. Follow this order.

CRITICAL PETS:
a. Emergencies: If you are needed, help! If not, move on.
b. ICU/Critical Pets: Treatment Techs and TA’s handle this.

CRITICAL CLIENTS:
c. Doctor Appointments: Doctors and Room Techs
d. Express TA Appointments: Express TA’s

UNSCHEDULED:
e. Walk-ins/Urgent Care Visits: Only after appointments
f. Advance Appointments: Extra unscheduled services come
after scheduled appointments.
g. Drop-Offs: Finish when caught up or in-between above.













[71]

Block-Off Times:
Saturdays
 Exam Room 3 (Start Time 8:00 am)
o E-Slot (20 minute)
 9:40 – 10:00 am
 1:40 – 2:00 pm
o Buffer
 11:40 – 12:00 pm
 3:40 – 4:00 pm
o Out of Office (Lunch)
 12 – 1 pm
 Exam Room 4 (Start Time 8:10 am)
o E- Slot (20 minute)
 10:00 – 10:20
 1:50 – 2:10 pm
o Buffer
 11:40 – 12:00 pm
 3:40 – 4:00 pm
o Out of Office (Lunch)
 12 – 1 pm
Sundays
 Exam Room 3 (Start Time 10:00 am)
o E-Slot
 11:40 – 12:00 pm
o Buffer
 1:40 – 2:00 pm
 Exam Room 4 (Start Time 10:10 am)
o E-Slot
 1150 – 12:00 pm
o Buffer




























[72]

Receptionists for Exam Room Efficiency:


 Stagger appointments so that no appointment starts at the same time.
o Schedule appointments 10 minutes later than appointment on opposite room
o FOR OWNERS WITH MUILTIPLE PETS - schedule in THE same exam rooms to maintain
exam room efficiency. Schedule each pet the appropriate length of time for THAT
INDIVDUAL PETS APPOINTMENT so both pets’ times are added together.
- Example: If one owner is bringing in two pets for annual visits each pet is
scheduled for 20 minutes back-to-back in the SAME ROOM as it happens. We
realize there may be another appointment 10 minutes after starting this one. It
may be delayed a few minutes. That’s okay.
 DO NOT add space or block-offs between appointments.
 DO NOT scheduled the same TYPE of appointment within 10 minutes of each other.
 New Clients need to come in 10 - 15 minutes prior to their appointment to fill out necessary
paperwork and to allow sufficient time to copy records and enter information into the database
 Authorized to remove E-Slots on the scheduled appointment day
 Check-IN Receptionist: Working from the front station facing the front doors.
o Checking IN clients for all services as they arrive.
o Directing the clients to the correct next staff member and moving on to the next client
check-in (example: appointments weighed and paged overhead, grooming patients
weighed and paged overhead, express TA check-ins/outs paged overhead, etc.)
o Makes all OUTGOING CALLS (minus confirmation calls)
o Printing treatment plans, cage cards, ID collars, etc. for tomorrow’s appointments.
o Helping the check-out receptionist FROM THE CHECK-IN AREA if “traffic” gets backed up.
 Check-OUT Receptionist: Working from the check-out room
o Checking OUT clients for all services as they are leaving
o Answering incoming lines – should be able to handle up to 3 lines by yourself.
o Helping the check-in receptionist FROM THE CHECK-OUT AREA if “traffic’ gets back up.
o Download lab work
o Confirmation calls




























[73]

Exam Room Technicians for Exam Room Efficiency:
 Room Techs can spend up to total length of appointment time (20-40 minutes) total.
 Assure your appointments are finished on time in order to start the next on time IN THE SAME
EXAM ROOM.
 Any times spent longer than above puts us behind.
 Transfer ALL treatments and labs done OUTSIDE THE EXAM ROOM to the treatment tech or TA
team.
o If they are too busy to take the patient right then:
- Label a cage card with patient name and client last name.
- Put the patient in an ICU cage.
- Write on the Tech board exactly what labs/tx’s you need done.
 On Saturday, if something is going to take longer than the allotted schedule time coordinate first
with the staff veterinarian to recommend a patient drop off in order for the treatment team to
complete the work.
o Have client sign “Medical Release Form” and clarify a good phone number to reach
them
 Any pets left for the treatment team must be:
o Personally handed to the treatment team with instructions… -- OR --
o Placed in ICU cage with cage card and instructions on treatment board.

Treatment Technicians and Treatment TA’s for Exam Room Efficiency:
 Complete all treatments and labs as indicated by the veterinarian and room technicians
 Turn patients back over to the room tech when done.
 Turn lab results in to doctor when they are done.
 Watch Tech board closely and mark any items as completed on Tech board.
 Triage patients appropriately. (Example: Emergency, ICU, Appointments, surgery, then drop
offs, boarding, etc.)
 Make sure all patients STAY labeled appropriately and no pets are left unattended outside of a
cage.































[74]

Veterinarians for Exam Room Efficiency:
 Efficient visits
o Start and End on Time – Appointments must be finished within the scheduled time (20-
40 minutes) at last 90% of the time.
o Spend less than 10 minutes for
 Time in exam room and
 Time to dictate tech sheets to exam room technician
 Records must be completed between appointments 90% of the time. It is
acceptable to delay an appointment up to 3-4 minutes in order to complete the
last patient’s records.
 Any times spent longer than above puts us behind resulting in
 Unsatisfied clients
 Stressed staff
o Maintain good and clear communication with clients and staff
o Client CALLS are conducted during breaks, lunch, before or after hours
 Exception:
 Pets currently under care or in the hospital
 Referral calls from other veterinarians


















































[75]

Exam Room Efficiency Drill:

1. With a diagram or floor plan drawn out on paper we use demo pieces to represent the:
a. client,
b. patient,
c. room tech,
d. treatment tech,
e. treatment TA
f. doctor
g. clients and patients in exam room waiting
2. Draw on another sheet of paper appointments in two exam rooms staggered with times as per
the scheduling grid. Basically draw the schedule as it would look in AVImark with the doctor
name. Write the tech name above each exam room.
3. Using the demo pieces show where all of the demo pieces would go as the appointments in the
two exam rooms as you verbally say the 10 minute times.

Example: Ear infection –
 At 10 AM the room tech escorts the client to the exam room.
 From 10 to 10:08 Dr. Julius in the exam room with room tech, client and patient.
 From 10:08 to 10:10 Dr. Julius moves to his office with room tech to dictate the tech sheet with
ear flush.
 From 10:10-10:14 the room tech prints the treatment plan and goes over it with client.
 At 10:15 the room tech moves the patient to the treatment room, transfers info to the treatment
tech team to complete things.
 10:15-10-20 – the room tech prints all meds and release instructions.
 10:20-10:25 – the room tech goes over all meds, schedules recheck, and escorts client the
reception area.
 10:25 – the room tech escort the patient to the client in the reception area after all treatments
have been completed.
 10:30 – the room tech cleans the exam room and gets it ready for the next appointment. They
have 10 minutes to spare. They can help others, make a couple client calls, or be ready for the
next appointment early.

























[76]

1038 – Fecal Positives

Results Statement: To assure continuity of care and client service among all doctors
in regards to positive fecal results.

We recommend negative fecal tests yearly on each pet. If a
household has multiple pets with difficulty knowing which pet
belongs to which fecal sample, we do one fecal per pet per year.
For example: Four pet households would need to have four
fecal tests ran per year on separate samples.





Position with Overall Accountability: Associate DVM’s

Intestinal Parasites (non-tapeworms):
a. De-worm ALL dogs in household TWICE approx. 2-3 weeks apart. Assure we have
examine patient within the last year to be able to prescribe medication.
b. Change fecal reminder date on ALL dogs for approx. 4 weeks later.
c. Add Follow-up call to at least one dog for when fecal is due.
d. Discuss environmental control with owner.



Exceptions: Some parasites such as giardia and coccidia would require a different de-
worming doses. In which case we would retest the fecal centrifugation approximately one
week after finished.

Tapeworms:
a. Recommend fecal centrifugation to check for all parasites
b. Strongly recommend flea control product.
c. De-worm ALL dogs in household TWICE with praziquantel or Drontal Plus approx. 2-3 weeks
apart.
d. If first fecal result was negative there is no need for retesting of fecal.
e. If tapeworms are seen on a boarder the DOCTOR will call the client and recommend and
fecal test. Deworming is required, fecal test is recommended.

Drill/Quiz for Positive Fecals:
1. Do you deworm all dogs in the household?
2. What two things do you change in AVImark?
3. Is there a need to do a fecal test repeat when it was only tapeworms?







[77]

1040 – Feline Root Resorption Lesions


Dr. Tony Woodward, DVM, Dipl. AVDC
5520 N Nevada, Suite 150
Colorado Springs, CO 80918
719-536-9949
www.wellpets.com

Cats with root lesions - Per Dr. Woodward - In general crown amputation has been the most
cruel inhumane technique implemented in veterinary medicine. Radiograph should be sent to
dental specialist if you suspect the root can be left. Cats do not show dental pain. If crown has
been amputated the cat will ACT fine but is not doing fine. Follow-up rads would be needed to
confirm that everything is okay.
Crown amputation is only indicated in very rare instances:
1. Radiographic type 2 resorption, not type 1. Almost indistinguishable root
2. No perio disease or inflammation.
3. Cut crown at level of alveoli
4. Drill below level of alveolar bone by 1-2 mm
5. Suture gingival



Plan: All TR lesions need to have extractions including roots and post extraction rads. If we
suspect the rads confirm Type 2 resorption we should e-mail the rad to Dr. Woodward for
consultation to determine the plan.
If there is conflicting information from another source about crown amputation provide Dr.
Julius the source and contact information.

There is no drill/Quiz. This is a reference procedure.




























[78]

1040.1 – Fentanyl Patches


Results Statement: To assure consistent patient care, staff confidence, and avoid
most client concerns by applying fentanyl patches in a standard
way for the vast majority of patients.







Primary Responsible Position: Doctors
Participating Positions: Techs and TA’s

How to Apply:

1. The pet’s coat is shaved to the skin (avoiding clipper burns)
to a clean square shape that is approx.. twice the size of the
patch to be applied.
2. The shaving is done either side of the chest just behind the
elbow (craniolateral thorax).
3. The shaved area is cleaned routinely and rinsed with
alcohol. No loose hair should remain in this area after.
4. The patch is warmed via your hand or skin for at least one
minute so the adhesive will stick better. This adhesive
sticking is THE only way it gets absorbed into the pet’s
bloodstream.
5. 1 drop of tissue adhesive (super glue basically) is applied to
each corner of the patch before it’s adhered to the skin.
6. Patch is held against the skin with your hand for at least one
minute to assure the adhesive sticks.
7. Elasticon is adhered to the skin and patch after application
covering the entire patch.



Drill/Quiz for “Fentanyl Patches”:

1. Why do we all adhere fentanyl patches the same way every time? What happens if we don’t?
For the clients? For the staff as a group?
2. Show your trainer how you would apply a patch and explain all steps in your own words.








[79]

1041 – Good Samaritan Cases

Results Statement: To help ALL pets in emergency situations, including those pets
brought to us by non-owners (good Samaritans). As a result, we
are helping the community by providing certain emergency
services free of charge.

Primary Responsible Position: Receptionist

What is a Good Samaritan case? A pet who is found (NOT by the owner) in need of immediate
emergency medical care AND is

What can we do for a Good Sam case?
 Provide a FREE emergency doctor exam
 Stabilize the pet for any critical issues.
 Manage any acute pain.
 This allows a Good Samaritan to have the pet examined
and stabilized with no financial obligation.
 The doctor can give the good Samaritan an estimated
cost for continued non-emergency care.
 Offer the contact info for local rescue groups for any
non-emergency care.


What is NOT a Good Samaritan case? A pet in good health that is found by a person who intends to
keep the pet and is willing to take financial responsibility for the
patient whether they keep the pet or not.

A pet in good health that is found and NOT in need of
immediate emergency medical care.

What can we do for a non-Good Sam case?
 Take care of the pet at the expense of the person that
brought us the pet.
 The person who brought the pet signs all routine
paperwork and pays any required deposits.
 We can offer a New Client Free Exam coupon after
routine paperwork and check-in.
 Offer the contact info for local rescue groups for any
non-emergency care.

Drill/Quiz for ‘Good Samaritan Cases:
1. Why do have this procedure? What would happen if we did not? If the staff did not know it?
2. Explain in your own words what is Good Samaritan cases and what we can do for them.





[80]

1042 – Grooms Needing Sedation

Result Statement: To assure the highest quality patient care and client service for pets
requiring sedation with grooms. We assure the pet is properly
scheduled for the client and our staff. We also assure the sedation is
safe.



Primary Responsible Position: Receptionist

How to Schedule: Follow the surgery scheduling guidelines (see separate procedure).
o Only scheduled on weekdays we are open until 8 PM.
o Scheduled on the DOCTOR’S schedule and GROOMER’S
schedule for the same time on both.
o Scheduled for one hour
o Scheduled before 3:00.

What to Tell the Client:
 No food or water after 10 PM the night before the groom
 Arrive between 7 and 7:30 AM
 Like surgeries there is no promised completion time.

Safety Requirements: Doctor exam is required if:
o A new patient or
o Hasn’t had an exam in the last 6 months,
Bloodwork is required if:
 Has not had a blood panel in the last 6 months (assures
organs can handle the medications).
 If bloodwork was done at another practice, our doctors
must review it prior to the sedation

How It Works: The doctor’s technician will monitor the sedation for safety.

For patients who have had a current exam AND blood test in the last 6
months the doctor will direct the technical staff on the time and type of
sedation/anesthesia without further testing.

For patient who have NOT had an exam OR blood test in the last 6
months a note will be left for the doctor to review the patient’s record.
The doctor will determine what time of tests or anesthesia will be
needed for that patient. This could vary based on level of patient’s
aggression, age, medical history, etc.






[81]

Drill/Quiz for Grooms Needing Sedation:

1. Why do we have this procedure? What if we did not follow this? What could happen to the
pet? To the client service? To the staff?
2. Explain how we schedule sedated grooms.
3. Explain how you would perform the sedation on a cat, for example.
4. Get a pass when both you and your trainer are sure you can do this independently.




































































[82]

1044 – Heartworm Positive Dogs

Results Statement: When dogs test positive for heartworms we follow the
guidelines of the American Heartworm Society. Clients can be
directed to their website if they have questions or concerns
about our plan at www.heartwormsociety.org

Primary Responsible Position: Associate DVM’s

Why we do it this way: Because the treatment involves a drug with a narrow margin of
safety, a large expense, and varies from vet-to-vet we will take a
detailed series of steps. This will assure two things:
1. Patients get the safest most effective treatment
2. Clients understand why this is the ONLY safe way to treat
their pet and decided upon by a group of professionals in
this field, not us.


Steps to take:
1. Call the owner to return with pet for a 20-minute doctor appointment at NO EXAM/CONSULT
CHARGE.
2. Print 4 treatment plans for the is visit – “Work With” > Estimates
a. Heartworm Workup – customized for what else is needed. Write on the page with a
sharpie “Testing” for the owner.
b. Heartworm Tx __ lbs Day 60 - Write on the page “Day 60” with a Sharpie for the owner.
c. Heartworm Tx __ lbs Day 90 – Write on the page “Day 90” with a Sharpie for the owner.
d. Heartworm Tx __ lbs Day 120 – Write on the page “Day 120” with a Sharpie for the
owner.
3. For this appointment the tech:
a. Presents the estimate for:
i. Heartworm Antigen test through Antech (It is not financially feasible for us to
carry the in-house snap tests.).
ii. Heartworm prevention if not on already
iii. Microfilarial test.
b. Draws the blood,
c. Gets the doctor.
d. Runs the blood slide and looks for microfilaria. If positive we do not have to run the
Antech test….If negative we do.
4. The Doctor goes and on a blank sheet of paper writes down the the four steps – Tests, Day 1,
Day 30, and Day 60. The doctor discusses what we do at each stage an why. The doctor also
discusses how it may be done by skipping steps at another vet but is not entirely safe. After the
vet assures the client understands the plan they turn it back over to the tech.
5. The tech or TA goes back into the room with the 4 pre-printed Treatment Plans. The owner
should schedule the “Testing” treatment plan at this point. If we get lucky and the follow-up
rd
test comes up negative we can cancel the treatments all together or run a 3 test.
See next page for doctor info on treatment protocol



[83]

Treatment guidelines per The American Heartworm Society as of February 2014

Day 0 : Dog diagnosed and verified as heartworm positive.
 Positive antigen (Ag) test verified with 2nd Ag or microfilaria (MF) test
 Clinical signs with one positive Ag test and MF test (for status)
 Begin exercise restriction.
 The more pronounced the symptoms, the stricter the exercise restriction
 Testing recommended by LVH to be safe:
Chest Rads, CBC/Chem/Lytes, UA, Blood pressure (“Heartworm Workup” in AVImark)
 If the dog is symptomatic:
o Stabilize with appropriate therapy and nursing care.
o Prednisone prescribed at 0.5 mg/kg BID 1st week, 0.5 mg/kg SID 2nd week, 0.5 mg/kg
EOD 3rd and 4th week

Day 1: Administer heartworm preventive.
 If microfilariae are present, pretreat with antihistamine and glucocorticosteroid, if not already
on prednisone, to reduce risk of anaphylaxis.
 Observe for at least 8 hours for signs of reaction

Day 1–28: Administer doxycycline 10 mg/kg BID for 4 weeks.
 Reduces pathology associated with dead heartworms
 Disrupts heartworm transmission

Day 30: Administer heartworm preventive.

Day 60: Administer heartworm preventive.
 First melarsomine injection 2.5 mg/kg intramuscularly (IM)
 Prescribe prednisone 0.5 mg/kg BID 1st week, 0.5 mg/kg SID 2nd week, 0.5 mg/kg EOD 3rd and
4th week
 Decrease activity level even further.
 Cage restriction/on leash when using yard

Day 90: Administer heartworm preventive.
 Second melarsomine injection 2.5 mg/kg IM
 Day 91 Third melarsomine injection 2.5 mg/kg IM
 Prescribe prednisone 0.5 mg/kg BID 1st week, 0.5 mg/kg SID 2nd week, 0.5 mg/kg EOD 3rd and
4th week
 Continue exercise restriction for 6 to 8 weeks following last melarsomine injections.

Day 120: Test for microfilaria. If positive treat with microfilaricidal and retest in 4 weeks.

Day 271 (9 months): Test for Heartworm antigen (6 months after completion of treatment)

Drill/Quiz for Heartworm Positive Dogs:

In your own words describe all the steps you will take when you get a heartworm positive case.


[84]

1046 – Hospitalized and ICU Patients


Results Statement: To assure the highest quality patient care by treating hospitalized and
ICU patients as a priority above all else except emergencies:





Primary Responsible Position: Associate DVM’s

ICU Orders:
 ALL ICU or hospitalized patients will have current ICU orders filled out and charges current.
 ICU Orders are found in the procedures manual under “Forms – Misc”.
 Print a patient label from AVIMark and put on the form to save time.
 Assure the techs complete orders as written AND enter charges real-time so they stay up-to-
date. The bottom row highlighted and initialed should assure this happens.

Doctor ALWAYS familiar with and prepared for all ICU cases:

 If a doctor is in the building these patient will always have doctor in charge of and familiar with
the case. This includes lunch hours, evenings, and the next morning.
o Doctors’ verbal or written communication is accomplished by any doctor in charge of a
case informing the NEXT DOCTOR of the case and the care BEFORE LEAVING THE
HOSPITAL. This communication can be very brief as the medical records should be kept
current along with charges and ICU orders.
o This prevents ANY hospitalized patient under our care from having a doctor in the
building not familiar with or in charge of its care. It also allows at least one doctor in the
building to always be able to communicate with the client about their pet’s status and
plan.


Drill/Quiz for “Hospitalized and ICU Patients:
1. Show your trainer where you would go to print an ICU order?
2. You have an ICU patient who is stable and you are going to lunch. There is another doctor on
staff during your lunch. What should you do before you go to lunch?
3. What if the same scenario happens and no other doctor is on staff during your lunch. Can you
go to lunch? If so what would you tell your techs?















[85]

1047 – Imaging Referrals

Results Statement: To assure patients needing images and scans are well cared for
and with ease for the client.






Primary Responsible Position: Associate Vets

How to Refer to CCVIC in Frisco:

1. Get signed approval for the scan or image from the client
2. Enter the charge in the patient’s record
3. Transfer the client to reception to pay for the charge before
referring.
4. Go to www.collincountyveterinaryimagingcenter.com
5. Complete the imaging request and fax or email to them
6. The CCVIC will contact the client to schedule the appointment
7. The CCVIC will send over the report by the end of the day

Reference Procedure. No need for a quiz or drill.





































[86]

1048 – Internet Pharmacies


Results Statement: To assure the highest quality patient care and client service. We
do this by assuring patients receive the safest and most
effective medications at a reasonable cost. Clients get this by
choosing the best pharmacy for them and their pet.



Primary Responsible Position: Receptionist

Participating Positions: DVM’s, Techs, TA’s

Who We DO Work with:
 We will approve ANY and ALL pharmacies endorsed by
the TVMA or AVMA.
 At the time of this procedure was written the
pharmacies we are aware of that are endorsed by
TVMA or AVMA:
o Our Website: www.legacyvet.com
o Vet’s First Choice
o Vetstreet
o Local Human Pharmacies approved by our dr’s
Who We DON’T Work with:
 We will not approve any meds from websites NOT endorsed
by the TVMA or AVMA.
 This include 1-800-PET-MEDS, Foster’s and Smith, and
others.
 Why Only Certain Pharmacies?
o Medications purchased from these discounters are
not guaranteed by the manufacturers.
o Our doctors cannot comfortably prescribe meds
using a place they cannot assure is effective and
safe.
 For example:
o If a client purchases heartworm prevention from a
discount website and the animal tests positive for
heartworms, the manufacturer of the medication
WILL NOT pay for medical treatment.
o If the client purchases heartworm prevention from
us or a TVMA or AVMA approved pharmacy and the
animal tests positive for heartworms, the
manufacturer WILL pay for medical treatment.







[87]

What to do:
 If the owner insists on using a non-approved pharmacy, our
doctors can write a script and the client may get it filled at a
place of their choice at their own risk.
 When we give the owner the written script, we will also give
the “Pet Internet Pharmacies” brochure while describing
the benefits of using a reputable pharmacy.
 Determine the difference in daily or monthly cost of using
our pharmacy vs. the one they want. Show the client the
difference.
 If it’s an approved pharmacy you give the script to the
doctor for approval.

Drill/Quiz for “Internet Pharmacies”:
1. Why do we have this procedure? What happens if we don’t know it? If we don’t use it?
2. What pharmacies do we approve from? Why?
3. What pharmacies do we NOT approve from? What could we do if the owner insists?
4. A client requests a med from 1-800-PetMeds. Role play with your trainer acting as a client.
Explain to the trainer (client) what you say to the client. Keep practicing until both you and your
trainer are comfortable you can do it while keeping a happy client and we have done all we can
to keep their pet safe.











































[88]

1050 – Ivermectin Sensitivity


Results Statement: To assure we recommend ivermectin safely.

Primary Responsible Position: Associate DVM’s


http://www.heartwormsociety.org/veterinary-resources/canine-guidelines.html#4

Macrocyclic Lactones
The heartworm preventives currently marketed (ivermectin, milbemycin oxime, moxidectin, and
selamectin) belong to the macrocyclic lactone class of drugs. These compounds have excellent
therapeutic/toxic ratios and affect microfilariae, third- and fourth- stage larvae, and in some instances of
continuous use, young adult heartworms. A filaricidal effect of oral and topical formulations on
precardiac larvae can be achieved by brief pulsing at very low doses, which makes these drugs nearly
100% effective when given following label instructions and among the safest used in veterinary
medicine.

All oral and topically administered macrocyclic lactone chemoprophylaxis products are labeled for a 30-
day dosing interval. Thereafter, efficacy against late fourth-stage larvae declines and is unpredictable.
Juvenile worms, which can be found as early as 52 days post infection, are even less susceptible to
chemoprophylaxis. As worms age, they require progressively longer-term administration to achieve a
high level of protection. The extended post-infection efficacy of the macrocyclic lactones is a partial
safeguard in the event of inadvertent delay or omission of regularly scheduled doses but does not justify
lengthening the recommended 1-month interval of administration for the oral and topical formulations.
The extent of efficacy against late fourth-stage larvae and juvenile worms has important implications for
chemoprophylaxis in dogs that have either missed doses during the transmission season, or are already
into the transmission season before chemoprophylaxis is started and may already be infected.
Continuous year-round administration of heartworm preventive is critical.


Some Collies and other P-glycoprotein deficient dogs are unusually sensitive to a variety of commonly
used veterinary drugs, including some antidepressants, antimicrobial agents, opioids,
immunosuppressants, and cardiac drugs (Table 1). The macrocyclic lactones are also included in this list
with toxicities being reported with overdosing or in combination with other P-glycoprotein inhibiting
drugs. Often these instances have occurred when concentrated livestock preparations of these drugs
have been accidentally ingested by a dog, or there has been administration of an improper dose to a
dog, typically due to human error in dose calculation with extra-label use of these products in dogs. The
standard chemoprophylactic doses have been shown to be safe in all breeds.


Table 1. Some Drugs and Other Substances that Inhibit P-Glycoproteins

Antidepressants
Fluoxetine
St John’s Wort
Paroxetine
Antimicrobial Agents
Erythromycin



[89]

Itraconazole
Ketoconazole
Opioids
Methadone
Pentazocine
Cardiac Drugs
Verapamil
Amiodarone
Quinidine
Nicardipine
Immunosuppressants
Cyclosporine
Tacrolimus
Miscellaneous
Bromocriptine
Chlorpromazine
Tamoxifen
Grapefruit juice

(Source: http://www.vetmed.wsu.edu/depts-vcpl/drugs.aspx)


Oral administration: Ivermectin and milbemycin oxime are available for monthly oral administration.
Some of these formulations are flavored and chewable to increase patient acceptance and facilitate
administration. Dose units are packaged for dogs within prescribed weight ranges. To be maximally
effective, heartworm prophylaxis should be given year-round, but if seasonal treatment is chosen,
administration should begin within one month of the anticipated start of transmission and should
continue for at least 3 months after transmission ceases.

Topical administration: Moxidectin and selamectin are available as a topically applied liquid. The
parameters for treatment with topical products are the same as for monthly oral chemoprophylaxis.


Parenteral administration: A single dose of the slow-release (SR) formulation of subcutaneously injected
moxidectin-impregnated lipid microspheres provides continuous protection for 6 months. Treatment
every 6 months is recommended for maximal protection.

This is a reference only procedure. There is no drill/quiz.





















[90]

1052 – Lab-work Requirements for Prescription Refills

Result Statement: To assure patient safety and consistent recommendations
for lab-work requirements on all patient regardless of
doctor.

Primary Responsible Position: Associate DVM’s

Guidelines:

 Lab work is required every SIX months on the following meds:
 In general, we never fill more than 90 days at a time. We do this because it causes to run out of
meds for other clients. It also can cause us to have to do a large refund at our cost if something
changes with the pet or the client.
 With more critical or dynamically changing conditions we fill less than 90 days, even on chronic
meds. An example would be Vetmedin where the dosage or condition may change.

Medication Lab Test Preferred
NSAID’s: NSAID monitoring panel

Corticosteroids (chronic) CBC, Chem or other similar panel.
Phenobarb: Phenobarb monitoring panel (cbc, chem., PB level)

Potassium Bromide: CBC, chem., bromide level
Thyroid: T4 level every 6 months for 2-3 times. If normal then yearly.
CBC/Chem minimum yearly.
Proin Renal profile or equivalent q 6 months.
Cardiac Meds Renal profile at minimum every 6 months or based on
recommendation

Heartworm Prevention: Yearly test on dogs, not required on cats
Antibiotics: We usually require exams with each request unless it is a special
case
What to do:
1. BEFORE refilling look through the patient’s REMINDERS and
RECORDS to be sure the pet has had the appropriate lab test.
2. ALWAYS ADD OR ADJUST REMINDERS to what lab-work that pet
needs and how often!


Why Adjust or Add Reminders: The adjusted reminders will automatically generate emails, post
cards, and phone calls (when overdue) to the client. This
eliminates confusion with the client AND staff who likely will not
know what labs our doctors will require. It eliminates stress and
wasted time.


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LAB WORK GUIDELINES FOR LAY STAFF:

12
Drop Tech Timing and
Test Reason hour
off visit Instructions
Fast
4-6 hours after
total T4 Thyroid monitoring No No Yes
morning pill
free T4 by ED Testing for Thyroid Disease No No Yes anytime


Low dose Dex Test Cushing's Disease Testing Yes Yes No best to start in AM

Cushing's monitoring or
ACTH Stimulation Test Yes Yes No best to start in AM
Addison's Testing
Urine Protein:Creatinine best done in AM with
Ratio Quantify protein in Urine No No Yes first urination


Cardiopet-proBNP Testing for Cardiac Failure No No Yes anytime

Fructosamine Diabetes Monitoring No No Yes anytime


CBC/CHEM/LYTES/UA General Labwork Ideally No Yes anytime


best to start in AM;
have owner feed, and
Blood Glucose Curve Diabetes Monitoring No Yes No
give insulin like normal
routine

Bile Acids Liver Function Testing Yes Yes No best to start in AM

Monitors phenobarbitol levels
Phenobarbitol Panel Yes No Yes anytime
and organs


Drill/Quiz for “Lab-Work Requirement for Prescription Refills”:
1. When refilling medications what do you do with the reminders? Why?
2. If doctors were to not adjust or add reminders what happens for the client? For the non-DVM
staff?


















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1054 – Lab-work Guidelines

Result Statement: To assure continuity of patient care and client service among all
doctors in regards to labwork.

To also assure we have smooth transitions with transfer of
handling labwork results from doctor to doctor.




Primary Responsible Position: Associate DVM’s

Participating Positions: Technicians

In-House vs. Antech:
 Most of our blood work is through Antech unless the pet is too sick and
there is not enough time to wait for the results (evenings, Saturdays, and
Sundays).
How to handle results:
 When speaking with clients tell them you “will call when the lab results
come in”. Don’t say “tomorrow”.
 Antech lab results faxes will be left in the doctor’s lab result box outside the
doctors’ office.
 We ONLY call clients between 9 AM and 9 PM, unless there is an emergency
situation, in order to respect their family bed times.
 Senior wellness report cards will be mailed to all clients with senior
wellness profiles within ONE WEEK of the panel. The phone consult based
on the results will occur as with other tests, on the day they arrive when
that doctor is working.
 After Senior report card is completed and mailed add a line to the last
follow-up with a date/time stamp stating “senior report card mailed”.
 Negative fecal and heartworm test results alone will be called by lay staff.
These negative results will not be given to the doctors.
 If patient needs future service or test, we add both:
1. Follow-up and
2. Reminder - with appropriate date(s).
















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Which Doctor Calls the client?
 The doctor calls every client with lab work results the next scheduled shift
that the doctor receives them.
o We add a “Follow-up” in AVImark of what was discussed.
o We will leave the vast majority of lab results client calls for the
doctor who examined the patient.
When a DIFFERENT Doctor calls:
 If one doctor is off the doctor on duty can call the sick patients with a plan.
In this case the examining doctor must leave a written note for the doctor
that will call the client so that they know to look for results.
 If one doctor is scheduled off work for more than 3 days and has pending
lab work that doctor should leave a note for the doctor that will call the
patient.
 Doctors should use their best professional judgment when reviewing lab
work, making a treatment plan, making a diagnostic plan, or scheduling
surgery for another doctor. The best end result of this judgment should be
what is best for BOTH the patient care AND client service.
 When reviewing lab work or treatment plans with clients for another doctor
we will leave a message for the other doctor to make the final call UNLESS:
1. Patient treatment is critical or in the best interest to
treat now.
2. Client requests or demands that the treatment plan or
further diagnostics start now, BEFORE the original
doctor is in to make the decision.







































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Which doctor gets the production:
 Standard cases: routine labs
o Examples: ALP recheck, chest rads next year, recheck renal profile,
PB monitoring panel, etc.)
o Goes under the drop-off doctor or doctor seeing the appointment.

 Management or complicated cases: Decisions after lab work must be made
more quickly or require more detailed knowledge of history:
o Examples: Glucose curve, surgery follow-ups, recheck exams, ACTH
stim after loading dose, etc.)
o PRIMARY concern is the best patient care and client service. The
basic guidelines for these heavily managed cases are:
1. We attempt to schedule the test with same doctor ON A
DAY HE/SHE IS WORKING.
2. If it’s an emergency, critical, or time-sensitive (results and
plan is needed soon) case the test will it simply goes to the
FIRST AVAILABLE doctor.
3. For all other cases the test will go under the doctor that is
has been recently managing the case, even if the doctor is
not working that day.

Drill/Quiz for “Labwork Guidelines”:
1. If you do a senior wellness what do you mail the client? Within what maximum time frame?
2. What times do we call clients? Why not before or after?
3. What do tell the client when you will be calling them with lab results?
4. If you call the client and the pet needs some future service or test what TWO things do you add?
5. Doctors: When do you call the client with results from YOUR tests? What shift?
6. Doctors: In your own words describe how or when you would transfer calling of lab work results
to another doctor or taking over the plan after?





























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1055 – Laser Therapy

Results Statement: To relieve pain and improve healing. We do this by properly
administering therapeutic laser and properly charging for this service.





Primary Responsible Position: Technicians

How it Works: Laser Therapy uses light waves to help with inflammation and pain in
patients. It is a medical proven fact that it works.

Information You Need: The vet should give you the following information:
1. Reason for Treatment: ex. Chronic pain
2. Type of treatment: P2P or Scan
3. How many points: 18 pts
4. Location: ex. Lumbar spine

How to Enter in AVImark: When laser therapy is prescribed this should be documented in a note
under laser therapy in the computerized medical record. Like this:







































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How to Use the Laser:
1. Put googles on yourself and the patient.
2. Make sure the laser machine is plugged in. We do not use the battery.
3. Turn the machine on with the rear lower right silver button.
4. Make sure the laser machine is PLUGGED in. We do not use the battery.
5. Turn laser machine "On" with the silver start/stop button on rear lower
right of the machine.











6. Choose the species:












7. Choose treatment regimen-ex chronic, P (for P2P), B (for black dogs), L
(for 18 pts).











8. Press the green start button

Drill/Quiz for “Laser Therapy”:
1. Go treat a joint on a pet, yourself, or your trainer. There is no harm

[97]

1055.2 – Medical Record Efficiency


Results Statement: To assure all medical records are completed in a manner legally
required and thorough enough for the next vet to continue the
care….BUT also completed quickly enough that doctors can
complete 90% of all records before the next patient AND GO
HOME ON TIME.



Primary Responsible Position: Veterinarians
Why: Avoid client wait times. Keep doctors happy with a great work-
life balance. Save the next doctor of record time in reading your
SOAP’s.

When to Complete Records: Write as you go! Complete records between patients.

How Long Should Each Record Take? 5 minutes or Less (90% of the time)
What Happens if it Takes 10 minutes? On average doctors taking 10 minutes per medical record will
work 6 hours MORE per week, just on records. (75 pets X 5 min)

No Fear! You are 100% legally protected with this record writing. All
pertinent notes will be there! It will be obvious if you are
omitting something legally required.

Tips:
 Abbreviate!
 Write only what’s necessary for you or the next doctor needs.
 Don’t write in sentence form. Don’t write narratives.
 Don’t write what treatments or meds are given. They are
already listed in the medical line items.
 Don’t write what the clients decline. It’s in the line items.
 Don’t everything you discussed in appointments. It’s obvious
vets discuss issues noted on the exam and line items.
 Use templates as much as possible! You should never have to
type out all things that are normal. Templates have this all
listed with 1-3 clicks. It will save you













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Examples:

Not Efficient: Noted to the owner that the ears are mildly
irritated and that could be part of the reason she scratches her
face so much, but she also has a very large hot spot present on
her back legs. This is going to be very irritating and make the
itching worse.
Same Notes Efficiently: Mild ear irritations likely cause for
pruritus on face. 6 cm pruritic hot spot L. Lat jaw.



Not Efficient: She is going to need an e-collar to prevent her
from chewing at the area as that will continue to delay healing.

Same Notes Efficiently: E-Collar needed 24/7 X 7d



Not Efficient: Clavamox 250 mg PO BID X 14d #28.

Same Notes Efficiently: (No need to write this AT ALL. It’s in
the line item.


Reference Procedure Only. No need for a drill/quiz.
Follow this if you want to make more money and go home on time every day.

































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1055.2 – Overloaded, Sick Doctor, Rescheduling Clients?

Results Statement: To achieve both great patient care and client service during the busiest
times or when we don’t have enough doctors or staff. We do this by
CONSISTENTLY choosing how to handle the day, regardless of WHO is
deciding.

Primary Responsible Position: Executive Director

Participating Positions: ED  Lead Receptionist  Doctors  Receptionists
(In that order)

When this Applies: Occasionally there is simply too much to do in order to avoid reasonable
wait times, great patient care for every pet, and reasonable comfort/job
satisfaction for our staff. This typically happens from either too many
missing key staff/doctors or multiple emergencies.

When this does NOT Apply: Veterinary medicine FREQUENTLY involves high stress busy situations.
This is normal for our industry. We adjust, triage, and work hard to take
care of everyone.

What NOT to Do: “We cannot take any more emergencies, sick, or hurt pets.”
RESULT: Clients will choose other vets. It’s bad for the client, pets, and
us.

“Take in every client/pet and we will figure it out”.
RESULT: Long wait times, staff frustration and clients choosing other
vets. Lowered compliance. It’s bad for the client, pets, and us.
RESULT: Staff will be so frustrated and unhappy they will not perform
well….and likely start resigning.






























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