General Practitioner Template

NHS GP - EMIS consultation headings

A professional General Practitioner template for healthcare professionals.

About this template

Looking for a streamlined way to document patient consultations? This NHS GP EMIS consultation headings template is designed for General Practitioners to efficiently capture key information during patient visits. This template allows you to quickly record problems, history, examination findings, social context, and a clear plan of action. It's perfect for busy practices, ensuring comprehensive and accurate medical records. With Heidi, this template can be automatically populated from your consultation transcript, saving you time and improving the quality of your documentation.

Preview template

Clinician Specialty: General Practitioner Date: 1 November 2024 Problem: - I10 (Essential (primary) hypertension) History: - Patient presents today with a follow-up for hypertension. Reports occasional headaches and feeling generally well. Blood pressure readings have been slightly elevated at home, prompting this review. - Past medical history includes hypertension diagnosed 5 years ago, and a previous episode of mild depression treated with medication. - Medications include: Lisinopril 20mg daily, and Sertraline 50mg daily. - No known allergies. Examination: - Blood pressure: 140/90 mmHg. Pulse: 78 bpm, regular. Cardiovascular and respiratory examinations are unremarkable. Social: - Patient is a non-smoker and drinks alcohol occasionally. Works full-time as a teacher. Comment: - Impression: Hypertension is well-managed but requires ongoing monitoring and lifestyle advice. - Plan of action: Continue current medication. Advised on home blood pressure monitoring. Review in 3 months. Discussed lifestyle modifications including diet and exercise. No referrals are needed at this time.

Problem: - [insert SNOMED compliant diagnosis/problem code] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) History: - [describe current issues, reasons for visit, discussion topics, history of presenting complaints etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [describe past medical history, previous surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention medications and herbal supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [mention allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: - [describe physical examination findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Social: - [describe social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Comment: - [impression] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) - [plan of action] (Include planned investigations, referrals and follow-up. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) (For each section, only include if explicitly mentioned in transcript or context, else omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)

Browse more templates

Use this template