General Practitioner Template

🇬🇧 NHS GP Consult

A professional General Practitioner template for healthcare professionals.

About this template

Streamline your general practice consultations with this comprehensive NHS GP Consult template. Designed for General Practitioners, this template provides a structured framework for documenting patient encounters, whether face-to-face or via telephone. Capture essential details from the patient's history, including presenting complaints, ideas, concerns, expectations (ICE), and relevant risk factors. Easily record examination findings, vital signs, and any investigations or results. The template guides you through forming a clinical impression, listing diagnoses, and outlining a clear management plan, including investigations, treatments, referrals, and crucial safety-netting advice. Ideal for busy GPs seeking efficient and thorough documentation for every patient visit, ensuring all pertinent clinical information is systematically recorded.

Preview template

Clinician Specialty: General Practitioner F2F Seen alone Current issues History: - History of presenting complaints: Mr. John Smith, a 45-year-old male, presents with a 3-day history of a productive cough, clear sputum, and mild shortness of breath. He reports associated generalised fatigue and a low-grade fever (max 38.2°C) which he has been managing with paracetamol. Symptoms started after attending a crowded concert. Denies chest pain, haemoptysis, or significant wheezing. - ICE: Mr. Smith is concerned he might have developed a chest infection and is worried about it progressing to something more serious like pneumonia. He hopes for a prescription for antibiotics to clear it up quickly so he can return to work. He expects to feel better within a few days of treatment. - Red Flag: No reported haemoptysis, severe chest pain, stridor, or significant increase in shortness of breath at rest. No signs of confusion or reduced consciousness. - Risk Factors: Smokes 5-10 cigarettes/day for 20 years. No known history of asthma or COPD. Works as an office administrator. - PMH/PSH: Hypertension well-controlled on medication for 5 years. No significant surgical history. - DH: Amlodipine 5mg OD. Paracetamol PRN for fever. - Allergies: Penicillin (rash). - FH: Father had a history of chronic bronchitis. Mother has Type 2 Diabetes. - SH: Lives with wife and two children. Social smoker (5-10 cigarettes/day). Occasional alcohol (2-3 units/week). Denies illicit drug use. No recent travel abroad. No carers. Examination: - Vital signs: T 37.8°C, Sats 96% on room air, HR 88 bpm, BP 132/84 mmHg, RR 18 breaths/min. - Physical or mental state examination findings including system-specific findings: General: Alert and oriented, mild respiratory distress noted on exertion. ENT: Mild pharyngeal erythema, no tonsillar exudates. Chest: Good air entry bilaterally, scattered coarse crackles heard in both lung bases, no wheeze. CV: S1 S2 dual, no murmurs. Abdo: Soft, non-tender, no organomegaly. - Investigations and results: Point-of-care CRP: 25 mg/L (mild elevation). Impression: Acute lower respiratory tract infection, likely viral given the onset and current CRP level, but bacterial infection cannot be entirely ruled out. 1. ?Acute Bronchitis Plan: - Investigations: None at this stage, will review CRP if symptoms worsen or persist. - Treatment plans including medications if discussed: Advised conservative management with adequate rest and hydration. Continue paracetamol for fever/discomfort. Provided safety-netting advice regarding worsening symptoms. No antibiotics prescribed at this time given likely viral aetiology and mild presentation. - Referrals required or advised: None at present. - Follow-up arrangements including timeframe, setting or instructions: Review with GP in 3-5 days if symptoms not improving or worsening, or sooner if red flag symptoms develop. Advised to book a routine appointment. - Safety netting advice: Return immediately or contact 111 if experiencing severe shortness of breath, chest pain, confusion, coughing up blood, or if symptoms are significantly worsening despite self-care measures. Call 999 for emergency if sudden severe breathing difficulty or collapse.

[Consultation type: face-to-face "F2F" or telephone "T/C"] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) [People present during consultation, e.g. seen alone or with someone] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) [Reason for visit such as whether this is a follow up, booking note, current issues, etc ] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) History: - [History of presenting complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - ICE: [Patient's Ideas, Concerns and Expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - Red Flag: [Red flag symptoms relevant to the presenting complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - Risk Factors: [Relevant risk factors] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - PMH/PSH: [Past medical or surgical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - DH: [Drug history or medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - Allergies: [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - FH: [Relevant family history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - SH: [Social history including living situation, occupation, smoking, alcohol, drugs, travel or carers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) Examination: - [Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely. List in the order: T for temperature, Sats % for oxygen saturation, HR for heart rate, BP for blood pressure, RR for respiratory rate.) - [Physical or mental state examination findings including system-specific findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - [Investigations and results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) Impression: [Clinical impression or problems identified by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely. Do not infer or assume a diagnosis.) 1. [Diagnoses or differential/likely diagnoses as mentioned by the clinician] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely. Do not infer or assume a diagnosis. Write as a numbered list. Add a “?” before every differential diagnosis.) Plan: - [Investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - [Treatment plans including medications if discussed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - [Referrals required or advised] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - [Follow-up arrangements including timeframe, setting or instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.) - Safety netting advice: [Symptoms or situations requiring GP call-back, 111 contact or A&E/999 attendance as appropriate] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit entirely.)

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