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Antenatal and shared-care visit template

Australian documentation guide

Keep the details of an antenatal visit easy to follow: the person's concerns, current findings, results reviewed and who will take the next steps. Use it alongside the pregnancy record and your local maternity service's forms.

The blank template

How to fill it in

  1. Copy the blank template into your record system.
  2. Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
  3. Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.

A shared-care note helps everyone involved follow what happened at this visit and what needs to happen next. Use it alongside the pregnancy record and your maternity service’s own forms.

The SA shared-care guideline is one example of how services coordinate records and result follow-up. Local arrangements vary. This guide helps with documentation; it supplies no antenatal test schedule or treatment protocol.

Gestation

Include the stated weeks and days, established estimated due date and dating source where available. Make an approximate estimate from the person clear, rather than presenting it as verified dating.

“Dating recorded in the pregnancy record” or “reported estimate” can be helpful. Keep an earlier gestation tied to its date. The note must not calculate a new gestation or change a due date from incomplete information.

Maternal wellbeing

Capture the person’s concerns, questions and preferences, including effects on daily life and relevant psychosocial discussion. Separate their account from measurements and examination findings.

Keep answers about symptoms, fetal movements or mental health within the scope actually discussed. “Denies bleeding when asked” is a specific answer; it does not show that every symptom was reviewed. An absent discussion remains a gap.

Examination

Describe the examination performed, measurements with units and the clinician’s interpretation. Include blood pressure, fundal height or fetal-heart findings when assessed; this heading does not prescribe an examination.

Say when a measurement was taken in clinic, reported from home or limited by remote contact. A single reading or an absence of concerns does not establish normal growth or a reassuring overall assessment.

Investigations reviewed

Name the reports the clinician actually reviewed, with dates, sources and findings. Include the explanation given where recorded. Keep a person-reported result separate from a report seen by the clinician.

“Report requested”, “pending” and “reviewed” describe different stages. A report not seen cannot be called normal. For outstanding results, keep the agreed responsibility for obtaining, reviewing and communicating them visible.

Issues

Set out the concerns raised, the clinician’s assessment and anything still unclear. A symptom, confirmed diagnosis, possible concern and booking question may all need a place here, with their status made clear.

Keep uncertainty in the clinician’s words rather than adding a complication or risk category. Relevant medicines, allergies and background discussed can stay in this section or the linked record. This visit template does not replace a full pregnancy history.

Plan for next visit

Write down the agreed actions, who will take them and any timing discussed. Include result follow-up, communication with the maternity service and next-visit arrangements. Keep medicine, supplement and other instructions exactly as given.

A proposed visit is not a confirmed booking. Sending a result copy does not establish that someone accepted responsibility for review. The note must not add routine tests, injections, supplements or return advice from gestation alone.

Common omissions

Check the dating source, units, result status and who will communicate outstanding results. Keep examination limits, information provided and appointment status clear. A shared-care heading does not establish acceptance into a local programme.

Review before saving

Read the note alongside the pregnancy record and encounter. Ask the clinician to clarify conflicting dating or results. Check findings, instructions and unresolved responsibilities. The clinician must explicitly confirm generated content before it is saved or shared.

Worked examples

A shared-care visit with a report still to arrive

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

GESTATION: Fictional in-person GP shared-care visit at 24 weeks and 2 days, using the estimated due date already established in the pregnancy record. Dating is not recalculated by the note.
MATERNAL WELLBEING: Person reports feeling well overall, with fatigue after work, and describes the baby's usual movement pattern. They deny vaginal bleeding when specifically asked. Other negative symptoms are not asserted in this extract. They ask who will arrange their next hospital appointment.
EXAMINATION: GP records blood pressure 116/70 mmHg and symphysis-fundal height 24 cm. Fetal heart activity is documented as heard; a numerical rate is not stated. An overall examination or growth assessment is not recorded here.
INVESTIGATIONS REVIEWED: GP reviews the available 20-week ultrasound report and records the report's stated findings in the pregnancy record. A separate blood-test report has not arrived and is not treated as reviewed or normal.
ISSUES: Fatigue and uncertainty about the hospital appointment are discussed. GP identifies the missing blood-test report as requiring follow-up. No new diagnosis or complication is stated in this extract.
PLAN FOR NEXT VISIT: GP will obtain and review the missing report and communicate it as agreed with the maternity service. Reception will clarify the hospital booking with the person's permission. A GP review in four weeks is proposed, not yet booked. Maternity-service contact details are supplied; no additional medicine, supplement or return-trigger instruction is stated here.

A remote contact with limited examination

Fictional example. Made up for this guide; no patient record was used. It shows how to write a record, with gaps left visible. It is not a care plan or a record to copy into someone's chart.

GESTATION: Fictional video contact. Person reports being about 18 weeks pregnant; the established due date and exact gestation are not available in this extract.
MATERNAL WELLBEING: Person asks about the status of an earlier investigation. Other wellbeing information is not established in the extract.
EXAMINATION: Physical antenatal examination is not performed during this video contact. No blood pressure, fundal height or fetal heart assessment is documented.
INVESTIGATIONS REVIEWED: Person mentions an earlier result, but the report is unavailable. It is not recorded as a result reviewed by the clinician.
ISSUES: Established dating information and the investigation report require clarification. The record does not establish a normal pregnancy assessment.
PLAN FOR NEXT VISIT: Clinician states that the report will be requested. Who owns the result review, appointment timing and any interim advice are not stated. This limited contact remains an incomplete draft for clinician review.

Related templates

Start a consult with this template, free

Approved for publication by Tyson, 4 October 2026

Sources

Free to copy and adapt this template and guide, including for use in your practice. Sources linked above retain their own terms.

Use this guide to help write the record. It provides no clinical advice. The clinician remains responsible for checking that the record is accurate and complete. Check Medicare requirements, statutory forms and local policies separately.