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History and examination template

Australian documentation guide

A detailed clinical record with distinct sections for the presenting history, background, examination, impression and plan. It helps organise a record without assuming which questions or examinations are appropriate.

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.

History

Establish the presenting concern, onset, course, relevant associated features and the person’s priorities. Identify the historian and any communication or recall limitation. Use “reports”, “denies when asked”, “uncertain recall” or a direct quotation to distinguish kinds of evidence.

A chronology should distinguish a symptom present now from a past episode. Do not fill a systems review with negative findings that were never elicited.

Past history

Record relevant conditions, procedures, medicines and reactions that were actually discussed, with source and timing where known. Separate confirmed history from an unverified record entry. A historical diagnosis does not establish its current activity or severity.

Family and social history

Establish the relationship and condition when family history was elicited. Record relevant living, work and support context from the person’s account. Distinguish “no history reported” from “not asked”; avoid assumptions about family structure, function or risk.

Examination

Document observations and examination findings actually obtained, using anatomical site, side, measurements and units when available. Descriptors such as “alert”, “tender”, “non-tender”, “symmetrical” or “limited movement” require a corresponding observation.

State limitations, including remote assessment, declined parts or an examination not performed. A list of headings is not a checklist of completed normal findings.

Impression

Record the clinician’s stated synthesis and degree of certainty. Attribute a previous diagnosis when it is background rather than a conclusion of this visit. Keep “possible”, “working diagnosis” and “confirmed” distinct; include a differential only if the clinician expressed it.

Plan

Record the agreed actions, their status and any stated responsibility or timing. Include a declined option or unresolved decision when discussed. Do not infer investigations, treatment or safety advice from the impression.

Common omissions

The historian, time course, examination limitations and the distinction between old and current findings often disappear in a condensed summary. Check that a relevant negative was elicited rather than assumed.

Review before saving

Read the history alongside the examination and impression. Confirm that the document does not claim a more complete assessment than occurred, and that the plan preserves the person’s stated decisions and the clinician’s actual instructions.

Worked examples

A focused examination of a forearm bruise

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.

HISTORY: Person bumped their left forearm yesterday. Tenderness is improving. They report no numbness and no loss of hand function.
PAST HISTORY: Person reports no prior injury to that forearm and no regular medicines. Broader history was not taken at this focused visit.
FAMILY & SOCIAL HISTORY: Person lives with a partner and is moving suburb. Family history was not discussed.
EXAMINATION: Clinician records a 4 x 2 cm bruise on the left forearm, intact skin, full active wrist movement and normal light-touch sensation in the hand. No other examination is documented.
IMPRESSION: Clinician records a left forearm soft-tissue contusion.
PLAN: Monitoring and contacting the practice if new concerns arise are discussed and agreed. No medicine is prescribed.

Documenting a history-taking visit with examination deferred

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.

HISTORY: Person attends to discuss how records will be transferred after relocating. The purpose of this encounter is administrative.
PAST HISTORY: Not reviewed in this visit.
FAMILY & SOCIAL HISTORY: Person reports moving suburb next month.
EXAMINATION: Deferred; no physical examination undertaken during this records discussion.
IMPRESSION: Administrative transfer of care.
PLAN: Practice will confirm the receiving service and process the transfer after consent documentation is completed.

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.