Keep the person's question, the pharmacist's assessment and the next steps in one clear record. Use this template to document a community-pharmacy consultation, including advice given and anything still needing follow-up.
How to fill it in
- Copy the blank template into your record system.
- Fill in what was discussed or assessed. Keep uncertainty visible, and use [not stated] where required information is missing.
- Check the details and any gaps before saving or sharing. The clinician must explicitly confirm any generated content.
A useful consultation note captures the person’s question, what the pharmacist found and what happened next. This template keeps the assessment, advice and follow-up together.
It records a consultation rather than deciding how a symptom should be managed. The pharmacist uses their own assessment, scope of practice, current references and service requirements. The PSA standards provide context for that professional work.
Presenting concern
Start with the person’s question, symptom or reason for visiting. Note who the consultation is about, who supplied the information and whether you met in person, by telephone or another way.
“Wants to clarify existing directions” or “asks about a product” can give helpful context. A product request alone does not establish a diagnosis or that supply is appropriate.
History
Include the history discussed: timing, changes, relevant symptoms, earlier actions and response. Identify information from a carer, another service or the dispensing record separately.
“Not asked”, “declined” and “denied when asked” describe different things. Keep unasked topics visible. A brief enquiry does not show that a full assessment happened.
Medications
List the medicines and non-prescription products discussed, with names, strengths, formulations, directions and current use where known. Note product checks and differences between sources.
A dispensing entry does not prove current use. Matching an active ingredient does not by itself verify matching strength, formulation or directions. Keep any unverified product details visible; the template supplies no dose or substitution advice.
Allergies and adverse reactions
Include the substance, reaction, timing and source where known. Keep a possible reaction reported by the person separate from the pharmacist’s assessment.
If allergy history was not obtained, leave the required gap visible rather than writing “no known allergies”. Keep an unidentified medicine unidentified until clarified.
Assessment
Use the pharmacist’s stated assessment, uncertainty and information still needed. Phrases such as “product information verified” or “further assessment needed” can make the limits clear.
The template must not diagnose, classify urgency, assess an interaction or recommend a medicine. Those conclusions belong to the pharmacist’s actual assessment.
Advice given
Write down the points explained, any information source or written resource provided, and the person’s response where discussed. Keep an explanation, recommendation, agreed action and product supplied distinct.
A leaflet does not show that every topic was discussed or understood. Record the actual advice and medicine directions rather than inserting a standard counselling list. If a question was answered, include the answer where known.
Referral and safety-netting
Include referrals, contact with another professional, urgency and return advice as given. State where and when the person was advised to seek care if those details were discussed.
“Referral discussed”, “service contacted” and “appointment confirmed” are different stages. Missing advice stays [not stated] for review. The unfinished enquiry below shows a documentation gap, not a suggested response to those symptoms.
Follow-up
Make the next step clear: what was agreed, who will do it, when and what remains unresolved. Distinguish a scheduled review from an invitation to contact the pharmacy or an action still under discussion.
Leaving the pharmacy or receiving a product does not establish resolution. A later outcome needs its own recorded contact and date.
Common omissions
Check how much history was obtained, which products were identified and whether allergies were discussed. Look for the actual advice, referral status and follow-up. Keep unfinished enquiries labelled as unfinished.
Review before saving
Read the assessment and advice against the conversation. Check medicine directions, product verification, sources and required gaps, as well as local documentation requirements. The clinician must explicitly confirm generated content before saving or sharing it.
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.