UK General Practitioner Consultation Template
The s10.ai GP Consult template is an all-encompassing resource crafted for General Practitioners to efficiently document patient consultations. This template meticulously addresses every critical component of a GP visit, including patient history, clinical examination, diagnostic impression, and treatment planning. It is especially beneficial for capturing comprehensive patient data, such as medical history, examination results, and therapeutic strategies. By utilizing this template, GPs can ensure precise and thorough documentation, which is vital for maintaining continuity of patient care. This template is perfect for UK-based GPs aiming to optimize their documentation workflow while ensuring the accurate recording of essential clinical information. By integrating with S10.AI — the AI medical scribe — this template streamlines documentation so clinicians can focus on the substance of the encounter, not the keyboard.
Organized sections for comprehensive clinical documentation
[face to face “F2F” OR if calling via telephone “T/C”] [indicate if the patient is alone or accompanied, e.g., “seen alone” or “seen with…” (based on introductions). ‘[Reason for visit, such as current issues, presenting complaint, booking note, or follow-up]’. History: - [Details of presenting complaints] - [ICE: Patient's Ideas, Concerns, and Expectations] - [Presence or absence of red flag symptoms pertinent to the presenting complaint] - [Relevant risk factors] - [PMH: / PSH: - include past medical or surgical history (if applicable)] - [DH: Drug history/medications (if mentioned)]. [Allergies: (only include if explicitly mentioned in the transcript, contextual notes, or clinical note, otherwise leave blank)] - [FH: Relevant family history (if applicable)] - [SH: Social history, e.g., living situation, occupation, smoking/alcohol/drugs, recent travel, carers/package of care (if applicable)] Examination: - [Vital signs listed, e.g., T, Sats %, HR, BP, RR, (as applicable)] - [Physical or mental state examination findings, including system-specific examination] (only include if applicable, and use as many bullet points as needed to capture the examination findings) - [Investigations with results (include only if applicable and if mentioned)] Impression: [1. Issue, problem, or request 1 (issue, request, or condition name only)]. [Assessment, likely diagnosis for Issue 1 (condition name only) (include only if mentioned)] - [Differential diagnosis for Issue 1 (include only if applicable and if mentioned)] [2. Issue, problem, or request 2 (issue, request, or condition name only)]. [Assessment, likely diagnosis for Issue 2 (condition name only) (include only if mentioned)] - [Differential diagnosis for Issue 2 (include only if applicable and if mentioned)] [3. Issue, problem, or request 3, 4, 5, etc. (issue, request, or condition name only)]. [Assessment, likely diagnosis for Issue 3, 4, 5, etc. (condition name only) (include only if mentioned)] - [Differential diagnosis for Issue 3, 4, 5, etc. (include only if applicable and if mentioned)] Plan: - [Investigations planned for Issue 1 (include only if applicable and if mentioned)] - [Treatment planned for Issue 1 (include only if applicable and if mentioned)] - [Relevant referrals for Issue 1 (include only if applicable and if mentioned)] - [Investigations planned for Issue 2 (include only if applicable and if mentioned)] - [Treatment planned for Issue 2 (include only if applicable and if mentioned)] - [Relevant referrals for Issue 2 (include only if applicable and if mentioned)] - [Investigations planned for Issue 3, 4, 5, etc. (include only if applicable and if mentioned)] - [Treatment planned for Issue 3, 4, 5, etc. (include only if applicable and if mentioned)] - [Relevant referrals for Issue 3, 4, 5, etc. (include only if applicable and if mentioned)] - [Follow-up plan (noting timeframe if stated or applicable and if mentioned)] - [Safety netting advice given (for example, if mentioned, state which symptoms would mean they need to call back GP OR call 111 (non-life-threatening) for out-of-hours GP or if deteriorates to attend A&E/call 999 in life-threatening emergency (include only the advice/options which are mentioned in transcript or contextual notes))] (Never create your own patient details, assessment, diagnosis, differential diagnosis, plan, interventions, evaluation, plan for continuing care, safety netting advice, etc. - use only the transcript, contextual notes, or clinical note as a reference for the information you include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript or contextual notes, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank.)(Use as many sentences as needed to capture all the relevant information from the transcript and contextual notes.)
Example of completed documentation using this template
F2F seen alone. Patient presents with a persistent cough and shortness of breath. History: - The cough has persisted for 2 weeks, with occasional wheezing. - ICE: Patient is worried it might be asthma and anticipates receiving medication to ease symptoms. - No red flag symptoms such as chest pain or haemoptysis. - Relevant risk factors include a history of smoking (10 pack-years). - PMH: Hypertension diagnosed 5 years ago. - DH: Currently taking Lisinopril 10mg daily. No known drug allergies. - FH: Father had COPD. - SH: Lives alone, works as a teacher, smokes 5 cigarettes a day, no alcohol or drug use. Examination: - Vital signs: T 37.2°C, Sats 95%, HR 78 bpm, BP 130/85 mmHg, RR 18 breaths/min. - Chest examination reveals bilateral wheezing. Impression: 1. Persistent cough. Likely diagnosis: Chronic bronchitis. - Differential diagnosis: Asthma, COPD. Plan: - Investigations planned: Spirometry to assess lung function. - Treatment planned: Prescribe Salbutamol inhaler for symptomatic relief. - Relevant referrals: Consider referral to a respiratory specialist if symptoms persist. - Follow up plan: Review in 2 weeks to assess response to treatment. - Safety netting advice given: If symptoms worsen or new symptoms such as chest pain or haemoptysis develop, contact GP or call 111. In case of severe breathing difficulty, attend A&E or call 999.
Common questions about this template and its usage
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