Creating a Medical Note

Medical notes are how you document what happened during a visit. viggoVet gives you a rich text editor, pre-built templates for different visit types, and AI-powered voice dictation that creates SOAP notes from your spoken findings. Notes live on the patient’s record and link back to the provider who wrote them.

When to create a medical note

Create a medical note after examining a patient, during a consultation, or any time you need to document clinical findings, treatment decisions, or follow-up plans

Opening the Add Record form

From the patient’s profile:

1. Open the patient’s profile and go to the Overview tab.
2. Click Add Record in the top-right area.
3. The Add Record modal opens.

From the Status Board: Open the Action Menu on any checked-in patient and click Add record.

From the Treatment Plan page: Click Create A Record in the dropdown menu attached to any patient’s Treatment Plan view.

The Add Record modal

The modal shows “Add Record” as the title with a cancel option to close. Inside you’ll see:

Record #1 (you can add more records in the same session)

Depending on what kind of record type you choose, some of these fields will appear:

Below the fields is the rich text editor with a full menu bar (File, Edit, View, Insert, Format, Tools, Table) and a formatting toolbar (paragraph styles, bold, italic, highlight, alignment, lists, indent, strikethrough, code view, and a person icon for template insertion).

At the bottom of the modal:

• + Add another record button (to create multiple records in one go)
• Cancel and Save buttons

Using templates

Your clinic can configure medical note templates that pre-fill the editor with a structured format. Templates are managed in Settings > Configurations > Medical Note Templates and include options like:

• Standard: Basic SOAP format for routine cases
• Follow-Up: For follow-up visits and ongoing treatment
• Surgical: Pre-operative, operative, and post-op documentation
• Emergency/Critical Care: Urgent cases with emphasis on triage
• Wellness/Preventive Care: Routine health examinations
• Discharge: Final documentation when a patient leaves care
• Telemedicine: For virtual consultations
• Diagnostic Imaging: Focused on radiographic or ultrasound findings
• SOAPIER: Extended format adding Intervention, Evaluation, Revision
• Speciality: Used by specialists (cardiology, etc.)

Each template has a name, a details description, and a pre-built body with headings and bullet points. For example, the Standard template includes SUBJECTIVE (Chief Complaint, History of Present Illness, Past Medical History, Current Medications, Owner Observations) and OBJECTIVE (Vital Signs) sections ready to fill in.

Tip: Templates save time on routine visits. Instead of writing the structure from scratch, pick a template and fill in the specifics. Ask your administrator to create templates for your most common visit types.

AI Medical Note Dictation

Click the ViggoVet AI Medical Note Dictation button (purple-bordered, with a microphone icon) to start voice dictation. When active, a waveform visualization appears showing the audio recording in progress, with elapsed time displayed (e.g., 00:00 / 00:10).

Two buttons appear during dictation:

• Pause (double bar icon): Pause the recording
• Confirm (checkmark icon): Stop recording and generate the note

When you confirm, viggoVet AI transcribes your speech and creates structured SOAP notes based on the selected template format. You can edit the generated text before saving

Note: Voice dictation requires microphone access in your browser. For better results in noisy environments, use an external microphone.

Record types

Medical notes are one of several record types in viggoVet. When you open the Record type dropdown in the Add Record modal, you’ll see:

Viewing records on the patient profile

On the patient’s Overview tab, records are listed chronologically (newest first). Each record shows:

• A colored type badge (e.g., “Diagnostic Record” in orange, “Medical Note Record” in green)
• The record details including title, provider, clinic name, appointment and a dropdown menu for exporting, editing and deleting record.
• Content preview (e.g., SOAP note sections with Subjective, Objective headings)
• Columns for Diagnosis, Added by, Health Bar, Related Invoice, Appointment, and Actions

Use the filters at the top to narrow down what you see:

• Date / Time filter to focus on a specific range
• Record Type dropdown (defaults to All)

What to do if something goes wrong

Can’t find the Add Record button: Make sure you’re on the patient’s Overview tab. The button appears in the top-right area of the Overview content section.

Template not available: Templates are managed in Settings > Configurations > Medical Note Templates. Ask your admin to create the one you need.

Voice dictation not working: Check that your browser has microphone permissions enabled for viggo.vet. Try refreshing the page. If using a built-in laptop microphone, an external USB mic works better in noisy clinics.

Note saved under wrong patient: Records are tied to the patient profile they were created from. Delete the note and recreate it on the correct patient’s profile.

Want to add multiple records at once: Click + Add another record at the bottom of the modal to add Record #2, Record #3, etc. in the same session.

Note: Contact the viggoVet help if any of these problems persist after following the instructions.