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Templates, Clinical notes, Private GP

Private GP SOAP note template

A private GP SOAP 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.

01SOAP 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 SOAP note

1Subjective

  • The reason for the visit, in the patient's own words where they are useful.
  • How long it has been going on.
  • Onset, course and what makes it better or worse.
  • What the patient has already tried, and what they hope this visit achieves.
  • Relevant past medical and surgical history.
  • Current medicines, including anything bought over the counter.
  • Allergies and the reaction each one caused, or a record that none are known.

2Objective

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

3Assessment

  • 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.
  • 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.

01SOAP note

SignedAI-assisted, edited by the clinician

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

Private GP SOAP note

1Subjective

  • Cough for three weeks, not improving.00:42
  • Worse at night. Clear sputum. No haemoptysis, no breathlessness.01:30

2Objective

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

3Assessment

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

4Plan

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

Subjective, Objective, Assessment and Plan. 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 SOAP note on your own structure, in a 15 minute video call.