General Practitioner Template

General Practitioner's note (custom) (South African Standard)

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

2 times

Type

Note

Last edited

25/8/2025

Created by

Hannes Burger

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About this template

Need a clear and concise way to document patient encounters? This General Practitioner's note template is designed for use by GPs and provides a structured format for recording patient information. It covers key areas like presenting complaints, medical history, examination findings, and a detailed assessment and plan. This template helps GPs to efficiently capture all the essential details of a consultation, ensuring comprehensive patient records. With Heidi, this template can be automatically populated from your consultation transcript, saving you time and improving accuracy.

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Main complaint: - Patient presents today with a three-day history of a cough, sore throat, and general malaise. Past medical history: - No significant past medical history. - Medications: None. - Social history: Non-smoker, drinks alcohol occasionally. - Allergies: NKDA. - Family history: Father with hypertension. Examination: - Temperature: 37.8°C, Pulse: 88 bpm, BP: 130/80 mmHg, RR: 18 breaths/min, SpO2: 98% on room air. - General: Appears tired but in no acute distress. - ENT: Mildly injected pharynx, no tonsillar exudates. - Chest: Clear to auscultation bilaterally. Assessment & Plan: 1. Upper Respiratory Tract Infection - Assessment: Likely viral upper respiratory tract infection. - Treatment planned: Advised rest, fluids, and paracetamol for symptomatic relief. Review if symptoms worsen or persist. 2. Hypertension - Assessment: Elevated blood pressure reading. Further monitoring required. - Investigations planned: Repeat blood pressure check in 2 weeks. - Treatment planned: Lifestyle advice regarding diet and exercise. Date: 1 November 2024