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Templates, Clinical notes, Private GP

Private GP follow-up note template

A private GP follow-up note template that sets out what belongs in each section, ready to adapt to your own clinic. Below it is the same note filled in by the wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated . Written by our clinical team, generic by design, with no dosing advice.

01Follow-up note

TemplatePrivate GP

Patient
[Name]
Date of birth
[Date]
Record number
[Number]
Clinician
[Name, registration number]
Consultation
[Date and time], [in person or video]

Private GP follow-up note

1Since the last visit

  • What has changed since the last visit, in the patient's words.
  • Results received since the last visit, and whether they were discussed.

2Examination

  • Temperature, pulse, blood pressure and oxygen saturation where relevant.
  • Findings on examination of the system involved, including relevant negatives.

3Review

  • The working diagnosis, and the differentials still being considered.
  • The clinician's reasoning, in a sentence or two.

4Plan

  • Investigations requested, and who follows up the result.
  • Treatment agreed, as prescribed in the prescribing record.
  • Any referral, and whether a letter to the registered GP is needed.

5Next review

  • What should prompt the patient to get back in touch, and how.
  • When the next review is due.

Draft

[Clinician name]

[Role], [registration number]

Signed [date], [time]

How the wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Follow-up note

SignedAI-assisted, edited by the clinician

Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person

Private GP follow-up note

1Since the last visit

  • Cough improving, now only on waking.00:35

2Examination

  • Chest clear bilaterally. SpO2 98% on air.04:10

3Review

  • Likely post-viral cough. No red flag features.05:05

4Plan

  • Review in three weeks. Chest X-ray if persisting.05:40

5Next review

  • Advised to call the same day with haemoptysis or breathlessness.06:20

Signed and filed

[Clinician name]

[Role], [registration number]

Signed [date], [time]

Questions

What goes in a private GP follow-up note?

Since the last visit, Examination, Review, Plan and Next review. Each section on this page lists what belongs in it, written for private gp.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

Come back to the note, written and ready to sign.

See the wai scribe write a private GP follow-up note on your own structure, in a 15 minute video call.