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Community pharmacist counselling note template

Australian documentation guide

Make a clear record of what was explained, what the person asked and what they understood. Use this template for a medicines counselling conversation, keeping verified directions and any questions still open easy to find.

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.

Good counselling notes help the next reader see what was explained, what the person asked and what they understood. This template brings those details together without assuming every standard topic was covered.

Use the medicine’s current information and the pharmacist’s own assessment for the counselling itself. This page supplies no medicine directions or warnings. The PSA patient-counselling standard provides professional context for the conversation and its record.

Medications counselled

Name the products discussed, including strength, formulation or device where known. Note who received the explanation and which information sources were checked. Make a single-product discussion clear rather than presenting it as a full medicine review.

“Container checked” or “device not yet identified” can help. A medicine on an old list was not necessarily discussed today. If no product was identified, this required field remains a gap.

Indication

Include the medicine’s stated purpose and where that information came from: a prescription, record, the person’s account or the clinician’s explanation. Keep uncertainty or disagreement visible.

“Person understands it is for…” describes their account. A medicine name alone does not supply a diagnosis or confirm its purpose for that person. Leave an undiscussed indication missing.

Directions and administration

Keep the directions verified or explained, with dose, route, frequency and duration where known. Note any technique demonstrated, communication aid used or label discrepancy still needing clarification.

An existing direction, a prescriber-authorised change and an unverified report are different events. Keep any dose or missed-dose instruction to the directions actually given. A telephone conversation alone does not show successful device technique.

Counselling points

Describe the topics covered, information provided, questions raised and answers given. “Label explained” or “device technique demonstrated” helps when that is what actually happened.

A leaflet is useful to identify, but it does not establish that its full contents were discussed. Matching ingredient names does not establish interchangeable products. Keep remaining product checks and unanswered questions clear.

Side effects and warnings

Include adverse-effect information, precautions, interaction advice and action instructions actually discussed. Keep the source and wording where known, along with any unanswered question.

If none were discussed, retain [not stated] for review. If only some topics were covered, describe that limit. An explanation about a possible future effect is different from a reaction already experienced; the note does not diagnose a reaction or assign urgency.

Adherence support

Describe the medicine-taking difficulty the person raised and the support offered or agreed. Include their preferences and any carer involvement discussed.

“Reports missed doses” or “agrees to try a written reminder” is more useful than a broad label. A dispensing interval alone does not establish missed doses, and choosing support does not show that medicine-taking has improved.

Patient understanding

Record what the person said back, demonstrated or still wanted to ask. Include teach-back or observed technique where it occurred. Concrete details help the next reader more than “understands”.

A carer’s understanding is separate from the person’s. Agreement, politeness or receipt of information does not prove comprehension. If an answer or technique check was not recorded, keep that gap visible.

Common omissions

Check product identity, directions and their source, topics actually covered and questions still open. Keep permission for carer involvement and limits on remote technique checks clear. Label a partial discussion so it cannot be mistaken for complete counselling.

Review before saving

Read the note against the conversation and verified directions. Check that it adds no standard warning list, treatment change or unsupported claim of understanding. Keep unfinished checks and required gaps visible. The clinician must explicitly confirm generated content before saving or sharing it.

Worked examples

A partial vitamin-product discussion, with checks and warnings still missing

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.

MEDICATIONS COUNSELLED: Fictional in-person counselling about the person's cholecalciferol 1000-unit tablets. Pharmacist verifies the container against the current GP medicine list; this is an existing regimen, not a new recommendation.
INDICATION: GP record states treatment of previously documented vitamin D deficiency. Pharmacist records that source rather than inferring an indication from the product name.
DIRECTIONS & ADMINISTRATION: Existing GP directions are one tablet daily. Pharmacist repeats those directions and shows where they appear on the current list. No dose change is agreed.
COUNSELLING POINTS: Pharmacist explains the active-ingredient names on the two containers and supplies written product information for the existing tablets. The second container's strength and formulation have not yet been verified. Person asks whether it should be added to the first; pharmacist explains that both name the same active ingredient, but product and directions checks are still outstanding. No substitution advice is recorded.
SIDE EFFECTS & WARNINGS: Pharmacist discusses the need to check with the pharmacy before adding another vitamin D product or changing the existing directions. Specific adverse-effect information is not recorded in this extract and is not replaced with an assumed standard list.
ADHERENCE SUPPORT: Person says they sometimes forget the existing daily dose. Pharmacist and person discuss keeping a written tick record; person chooses to try that approach. No claim of improved adherence is made.
PATIENT UNDERSTANDING: Person explains back that both containers contain the same ingredient and repeats the existing one-tablet-daily directions. Their question about which container to use first remains open pending product verification. Understanding beyond those stated points is not recorded. This partial discussion does not document completed counselling.

A carer's enquiry with directions still unclear

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.

MEDICATIONS COUNSELLED: Fictional telephone enquiry by a carer about an inhaler. Permission for discussing the person's medicine information is recorded separately; the inhaler name and device are not stated in this extract.
INDICATION: [not stated]
DIRECTIONS & ADMINISTRATION: Carer describes the label as unclear. The current prescription directions have not yet been verified, and no replacement directions are generated.
COUNSELLING POINTS: Pharmacist asks the carer to bring the labelled device and current list for clarification. Device technique has not been demonstrated or observed during this call.
SIDE EFFECTS & WARNINGS: [not stated]
ADHERENCE SUPPORT: Medicine-taking routine and support needs are not explored in this extract.
PATIENT UNDERSTANDING: Carer repeats the request to bring the device. The person's own understanding and administration technique have not been assessed. This is a limited draft, not evidence of completed inhaler counselling.

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.