General Practitioner Template

GP note (SOAP separate issues)

A professional General Practitioner template for healthcare professionals.

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Specialty

General Practitioner

Used

40 times

Type

Note

Last edited

5/12/2025

Created by

Chris Mills

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About this template

This GP note template, designed for General Practitioners, follows the SOAP format to document separate medical issues during a patient visit. It allows for detailed recording of subjective and objective findings, assessments, and management plans for each issue. This template is ideal for GPs managing multiple conditions in a single consultation, ensuring comprehensive documentation. The structured format aids in clear communication and continuity of care, making it a valuable tool for efficient and thorough patient record-keeping. This template is particularly useful for documenting complex cases with multiple diagnoses or symptoms.

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Issue 1: Hypertension Subjective: - The patient, a 55-year-old male, visited for a routine check-up and management of hypertension. He reports occasional headaches and dizziness. - Past medical history includes hypertension diagnosed 5 years ago and a cholecystectomy 10 years ago. - Current medications include Lisinopril 20 mg daily and a multivitamin supplement. - Social history reveals the patient is a non-smoker and consumes alcohol occasionally. - No known drug allergies. - ICE: The patient is concerned about his blood pressure levels and expects to maintain them within normal range. - No red flag symptoms mentioned. - Direct questions: No chest pain, no shortness of breath. Objective: - Blood pressure: 150/95 mmHg, Heart rate: 78 bpm, Weight: 85 kg, Height: 175 cm. - Physical examination: No abnormalities detected. - Recent blood tests show normal renal function. Assessment: - Uncontrolled hypertension, likely due to non-adherence to medication. Plan: - Reinforce the importance of medication adherence. - Increase Lisinopril to 40 mg daily. - Schedule follow-up in 4 weeks. - Consider referral to a dietitian for weight management. Issue 2: Seasonal Allergies Subjective: - The patient reports increased sneezing and nasal congestion over the past two weeks, especially in the mornings. - No significant past medical history related to allergies. - No additional medications or supplements for allergies. - Social history unchanged. - No new allergies reported. - ICE: The patient is concerned about the impact of symptoms on daily activities and expects relief with treatment. - No red flag symptoms mentioned. - Direct questions: No fever, no cough. Objective: - Nasal examination reveals mild swelling of the nasal turbinates. Assessment: - Seasonal allergic rhinitis. Plan: - Start Loratadine 10 mg daily. - Advise on allergen avoidance strategies. - Review in 2 weeks if symptoms persist. Consented for transcription