A consult note organised around the issues discussed, while keeping medicines, allergy history, background, findings and follow-up easy to find. Useful when several concerns share one encounter.
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.
Consult summary
Establish the reason for attending and the person’s priorities. Summarise what the visit covered without implying that every item in the record was reassessed. “Scheduled review”, “new concern” and “administrative discussion” identify different encounters.
Issues
Name each issue addressed and keep its history, findings and decisions recognisable. Ask which concern came first and whether an issue remains unresolved. Use a symptom description until a diagnosis has actually been stated. Do not make an unmentioned problem an active issue merely because it appears in an old record.
Medications
Establish which medicines were discussed and the source of the list. Record a name, strength, dose, route and frequency only when known; distinguish prescribed use from the person’s reported use. “Current”, “ceased”, “not taking” and “status unconfirmed” are different states.
Keep allergy and adverse-reaction history within Medications or identify the linked allergy record. Establish the substance, reported reaction and source. Distinguish an allergy, an adverse effect and an unverified entry without reclassifying them from guesswork. “No known allergy”, “not asked” and “history unavailable” must not be used interchangeably.
Past medical history
Record history relevant to the issues discussed, its source and dates where established. Distinguish an active condition from a resolved episode or a family member’s history. Do not turn copied history into a finding from today’s encounter.
Social history
Ask about context actually relevant to this consultation, such as living arrangements, work or available support. Attribute the person’s account and document their preferences using respectful, specific language. Avoid assumptions about support, substance use or safety from appearance or address.
Preventative history
Record preventive topics that were raised and any established dates, results or decisions. “Discussed”, “completed”, “declined” and “status unknown” describe evidence, not an automatically generated schedule. This section does not determine screening eligibility or recommend an interval.
Examination
Record findings obtained for the problems addressed, including site, laterality, units and encounter limitations. “Not examined” is more accurate than an empty heading that looks like a normal result. A remote visual observation is not a palpation finding.
Impression
Record the clinician’s interpretation for each issue, including its stated certainty. Keep separate issues separate and retain unresolved questions. Vocabulary such as “working impression” or “cause not established” prevents an uncertain account becoming a confirmed diagnosis.
Plan
Map each stated action back to its issue, identifying the responsible person, status and timing when known. Separate shared decisions from completed orders and from actions awaiting another service. Do not add a management step simply to fill the heading.
Common omissions
A long problem list can obscure the person’s priority, a medicine’s actual use and which issue an action belongs to. Older background entries need their source and status rather than an implied fresh review.
Review before saving
Check that every issue addressed has an intelligible account and that the impression and plan refer to the right issue. Confirm that allergies, medicine changes and unresolved matters retain their actual evidence and status. Leave absent information explicit rather than inferring a reassuring answer.
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.