Skip to main content
Heidi AI
EinloggenKostenfrei mit Heidi starten

Fragen Sie die KI zu Heidi:

General Practitioner Template

Consult General

A professional General Practitioner template for healthcare professionals.
Use this templateBrowse more templates
Browse more templates

About this template

Looking for a straightforward way to document patient consultations? Our 'Consult General' template is designed for General Practitioners, offering a clear structure for recording patient information. This template helps you efficiently capture key details like the patient's problem list, presenting complaints, examination findings, impression, and the plan for care. With Heidi, this template can be quickly populated from your consultation transcript, saving you time and ensuring comprehensive documentation. Simplify your note-taking process and focus on what matters most – your patients.

Preview template

Consult General General Practitioner 1 November 2024 Problem List 1. Hypertension: Controlled with medication. 2. Type 2 Diabetes Mellitus: Managed with diet and oral medication. 3. Osteoarthritis: Affecting both knees, managed with analgesics and physiotherapy. 4. Anxiety: Mild, managed with lifestyle modifications and occasional counselling. Presented with The patient, a 68-year-old male, presents today with a three-day history of a worsening cough and shortness of breath. The cough is dry and non-productive, and the shortness of breath is exacerbated by exertion. He denies fever, chest pain, or any recent travel. He reports a history of similar episodes in the past, usually resolving within a week. On examination General appearance: The patient appears his stated age and is in mild respiratory distress. Vital signs: Temperature 37.2°C, Pulse 90 bpm, Respirations 22/min, Blood pressure 140/88 mmHg, SpO2 94% on room air. Chest auscultation reveals scattered wheezes bilaterally. No other significant findings on examination. Impression Based on the history and examination, the most likely diagnosis is an exacerbation of chronic obstructive pulmonary disease (COPD). Differential diagnoses include pneumonia and acute bronchitis. The patient's history of similar episodes and the presence of wheezes support the diagnosis of COPD exacerbation. Plan. 1. Administer a salbutamol inhaler (2 puffs every 4 hours as needed for shortness of breath). 2. Prescribe a course of oral prednisolone 30mg daily for 5 days. 3. Advise the patient to continue his usual COPD medications. 4. Instruct the patient to monitor his symptoms and return to the clinic if there is no improvement or if symptoms worsen. 5. Schedule a follow-up appointment in one week to review his condition and adjust his treatment plan if necessary.
Problem List [summarize the patient's current active and resolved medical, surgical, and psychiatric conditions, and any significant social issues] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list with brief descriptions.) Presented with [document the patient's chief complaint and the history of the presenting illness, including onset, duration, character, relieving/exacerbating factors, and associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) On examination [detail findings from relevant physical examinations, including general appearance, vital signs, and system-specific findings pertinent to the chief complaint] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Impression [provide a concise summary of the patient's condition, including differential diagnoses and the most likely diagnosis, supported by findings from the history and examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write in a paragraph of full sentences.) Plan. [outline the proposed management plan, including investigations, treatments (pharmacological and non-pharmacological), referrals, and follow-up arrangements] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely. Write as a numbered list.) (Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
Browse more templatesUse this template

How to use this template

Step 1: Download the template
1Step 1

Download the template

Get started by downloading the template to your device

Step 2: Customize to your needs
2Step 2

Customize to your needs

Tailor the template to match your specific requirements

Step 3: Deploy and share
3Step 3

Deploy and share

Implement your customized template and share with your team

Browse more templatesUse this template

Start practicing with a partner

Care is better with Heidi
Use this template

Specialty

General Practitioner

Used

3 times

Type

Note

Last edited

8.10.2025

Created by

Pravin Rajakumar

Related Templates

Note

Bericht an den Gutachter

Anonymous

General Practitioner, Germany

Note

Psychotherapeutisches Sitzungsprotokoll (nach DPtV)

Medizinisches Expertenteam

General Practitioner, Germany

Note

Medication Review

Elisabeth Schuster

General Practitioner, Germany

Heidi AI

Heidi. Hält Ihnen den Rücken frei.

© 2026 Heidi. Alle Rechte vorbehalten.

Fachbereiche

  • Allgemeinmedizin

  • Fachärzt:innen

  • Psychologie

  • Therapeutische Gesundheitsberufe

  • Zahnmedizin

  • Tiermedizin

  • Studium & PJ

Compliance

  • Datenschutz

  • Trust Center

  • Compliance

Produkt

  • Preise

  • Downloads

  • Hilfe-Center

  • Systemstatus

  • Systemanforderungen

Über uns

  • Kontakt

  • Unternehmen

  • Kundengeschichten

  • Medien

  • Stellenangebote

    10+
  • Team

Ressourcen

  • Informationszentrum

  • Vorlagen-Community

  • Häufige Fragen

Rechtliches

  • Datenschutzrichtlinie

  • Servicebedingungen

  • Nutzungsrichtlinie

  • Barrierefreiheit

  • Impressum