Documenting a GP clinic day

aurii drafts the consultation note, the referral, the results letter and the certificate.

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Spoken at the end of the consultation

A chronic disease management plan review, synthetic patient.

Spoken in the consulting room Ambient capture

"Sixty two, six month review of his plan, diabetes, hypertension and stage three A kidney disease."

"HbA1c 8.1, up from 7.4 on metformin and empagliflozin. Pressure 148 over 88 here, 142 at home."

"Filtration rate 52 and steady, but the albumin creatinine ratio has gone from 8 to 34."

"He gets tightness across the chest walking up the hill, gone in two minutes. Trace is normal."

"Urgent cardiology referral, start aspirin and a statin, perindopril up to ten, bloods in four weeks."

"He drives a forklift, so a certificate for seven days, and add the dietitian to the plan."

Consultation note Management plan review · Demo patient · 62

Ready to sign

Reason for the visit

Six-month review of the GP management plan. Type 2 diabetes, hypertension, kidney disease stage 3a. HbA1c 8.1 percent, from 7.4, on metformin and empagliflozin. Blood pressure 148/88, 142/86 at home.

Results reviewed

eGFR 52, stable. Urine albumin creatinine ratio 34, risen from 8. Exertional chest tightness on an incline, relieved by rest in two minutes. Resting ECG normal.

Plan

Urgent cardiology referral. Aspirin and a statin commenced, perindopril increased to 10 mg.
Repeat renal function and albumin creatinine ratio in four weeks.

Plan review and capacity

Dietitian added to the team care arrangement
Unfit for forklift duties pending cardiology. Certificate for seven days.

Synthetic demo patient.

GP letterDrafted Discharge summaryQueued Billing3 items

Illustration of the drafting view.

The referral, drafted in the room

aurii drafts the consultation note, the referral, the results letter and the certificate from the consult as it is spoken. The referral carries the clinical question, the history, the medicines, the allergies and the results already taken, under the general practitioner's name.

Documents from one consultation

Draft The consultation noteReason for the visit, the measurements taken, the results against the last set, the plan for each problem.

Draft The referralClinical question first, then history, medicines, allergies and results taken. The urgent version says why.

Draft The results notificationThe result in patient terms: the value, whether it moved, what happens next.

Billing items are captured at the bedside against the episode, for your practice to claim. Billing.

Starter templates a general practice draws on

A practice works from the general starter set: the progress note for the consultation, the routine and urgent referral letters, and the work certificate.

Your letterhead and section order, set once, on every draft. The template set.

The referral out and the reply back

The referral drafts from the consult with the clinical question first, then the history, the medicines, the allergies and the urgency. The specialist reply lands on the same record. The general practitioner signs what leaves.

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