Bring the person's history, assessment findings and agreed next steps into a clear record. Use this general template alongside the requirements for the particular health assessment you performed.
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 health assessment can cover a lot of ground. This template helps keep the person’s history, findings and agreed actions together, while making the assessment’s limits clear.
It is a general record, so use the current MBS requirements for the assessment you performed. A “75+” or “45–49” title alone does not establish eligibility or completion of the required work.
Assessment type
Start with the assessment’s purpose, type, date and setting. Note who supplied information, relevant consent and any communication needs. Make it clear if this is a new, follow-up or partial assessment.
Name the actual programme or clinical purpose rather than simply “health check”. Record duration from the attendance information, not the note’s length. A generated note does not choose a Medicare item.
History
Include the medical, psychological, functional and social history discussed. Describe what the person can do, what help they use and where they have difficulty. Concrete details are more useful than a broad label such as “independent”.
Identify a carer’s account separately and note permission for their involvement where discussed. Keep declined questions, unavailable information and unasked topics visible. Missing history is not a negative finding.
Include the medicines and non-prescription products discussed within History, with directions, reported use and sources where known. If a separate reconciled list holds the details, identify it clearly. Keep relevant allergies and reactions here or in the linked record.
Reported use, a dispensing entry and a current authorised list are different sources. An earlier list does not establish that a medicine is still taken, unchanged or suitable.
Measurements and examination
Include the measurements, units and examination findings actually obtained. Note who measured them, when and how, where this matters. Keep the clinician’s interpretation separate from the value itself.
“Measured today”, “reported home reading” and “not examined” help the next reader understand the evidence. Keep earlier readings dated; leave an unperformed examination visibly unperformed.
Screening and risk factors
Describe the areas explored and the findings recorded. If a tool was used, include its name, recorded result and any limits. Keep a discussion, a completed test and a diagnostic conclusion distinct.
The required scope depends on the assessment type. A brief conversation does not establish normal cognition, and a missing record does not establish immunisation status. Leave missing scores and unstated risk conclusions for the clinician to clarify.
Issues identified
Set out the clinician’s conclusions and the concerns identified with the person. Include functional difficulties and information still needed. Keep an established condition separate from a possible issue needing further assessment.
Phrases such as “reported”, “requires clarification” and “not yet assessed” can help. A measurement or risk factor alone does not supply a diagnosis or priority order.
Recommendations, actions and referrals
Write down what was recommended, agreed, provided or sent, with an owner and timing where discussed. Include the person’s preferences and any declined action. Record an assessment report being offered or supplied when that happened.
Keep an option discussed separate from an issued referral or completed action. Treatment, screening intervals and support arrangements must come from the actual assessment. Check any required report or other document separately.
Follow-up
Make the next steps easy to find: the review arrangement, information still needed and who will follow it up. Distinguish a booking request from a confirmed appointment, and an ordered test from a reviewed result.
If timing or ownership was not discussed, leave that gap visible. Say clearly when the assessment remains incomplete.
Common omissions
Check the assessment type, day-to-day function, medicine sources, examination limits, report status and follow-up owners. Keep any work required for the particular assessment visible alongside this general template.
Review before saving
Read the note against the assessment and its current programme requirements. Check units, sources, explicit negative answers and gaps. The record does not certify completion of a Medicare service. 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.