A specialist reply body that distinguishes the assessment, care provided, medicine changes, requests to the GP and follow-up. It makes responsibility for the next steps explicit when that responsibility was stated.
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.
Diagnosis and impression
Record the specialist’s stated conclusion and its certainty. Distinguish an established diagnosis from a working impression or unresolved question. Do not infer a diagnosis from investigations or treatment alone.
History and findings
Summarise the relevant account and findings from this assessment. Identify information taken from outside records and examination limitations. Describe reported symptoms separately from observed findings, with dates where established.
Investigations and results
Record investigations reviewed, their relevant results and any outstanding status. Distinguish a result already reviewed from one ordered or awaited. Do not interpret a pending result or imply that an enclosure was sent without checking.
Management provided
Record what was actually done, discussed or offered at the specialist encounter. “Provided”, “discussed”, “declined” and “planned” are different statuses. A proposed intervention is not a completed one.
Medication changes
Record changes explicitly made, including the established medicine details, change and stated reason. Separate an authorised change from a recommendation for the GP to consider. Do not supply a missing dose or imply that the person has begun a newly prescribed medicine.
Actions for the GP
List the specialist’s explicit requests, with responsibility and timing when stated. Distinguish a request from an accepted handover or completed action. If ownership is unclear, leave it visible rather than assigning it by convention.
Follow-up
Record the agreed follow-up service, status and timing when known. Distinguish booked, requested and awaiting allocation. A review interval or discharge from specialist care must have been stated, not inferred from a reassuring assessment.
Safety netting
Record advice actually given, who received it and any stated contact or escalation route. Preserve the clinician’s wording and uncertainty. The template does not generate warning symptoms or instructions that were absent from the consultation.
Common omissions
A medication recommendation can be mistaken for an implemented change, and a request for the GP can look like an accepted responsibility. Pending investigations and follow-up status need explicit wording.
Review before sending
Check that conclusions retain their certainty and each proposed or completed action has the correct status. Confirm that medication changes, GP requests and specialist follow-up do not contradict one another. Check the intended recipient and enclosures in the letter workflow.
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.