General Practitioner Template

System One

A professional General Practitioner template for healthcare professionals.

About this template

Need a quick and easy way to document patient consultations? This 'System One' template is perfect for General Practitioners (GPs). It provides a structured framework for recording patient history, examination findings, diagnosis, and a clear management plan. This template ensures all essential information is captured, from presenting complaints to safety netting advice. It's designed to streamline your workflow and improve the accuracy of your clinical notes. With Heidi, this template can be quickly populated from your consultations, saving you valuable time and effort. This template is ideal for GPs looking for efficient and comprehensive medical documentation.

Preview template

History : Patient presents today with a 2-week history of a worsening cough, accompanied by a runny nose and fatigue. Onset was gradual, starting with a mild scratchy throat. The cough is dry and non-productive. No previous treatments have been tried. Triggers include exposure to cold weather. Patient's ideas, concerns, and expectations: Patient is concerned about having a chest infection and wants to rule out pneumonia. They expect to receive medication to alleviate symptoms and a clear diagnosis. Red flags: No shortness of breath, chest pain, or haemoptysis reported. Psychosocial background: Patient is a teacher, lives with their partner and two children. No significant stressors reported. Allergies: NKDA. Past medical history: Asthma (well-controlled with inhaler). Examination : Vitals: Temperature 37.2°C, Pulse 80 bpm, BP 120/80 mmHg, SpO2 98% on room air. Systems: Chest clear to auscultation. Mild rhinorrhea noted. No wheezing or crackles. Throat mildly erythematous. Chaperone: Chaperone was present. Diagnosis : Upper respiratory tract infection (URTI), possible viral aetiology. Plan : Shared management plan - Doctor's share: Advised rest, fluids, and paracetamol for symptomatic relief. Prescribed a course of antibiotics if symptoms worsen or if there is evidence of secondary bacterial infection. Provided advice on self-care and infection control. Patient's share: Patient to monitor symptoms and return if they worsen. Patient to take paracetamol as directed. Patient to stay home from work to avoid spreading infection. Safety netting and follow up: Advised to seek immediate medical attention if they develop shortness of breath, chest pain, or high fever. Follow-up appointment in 1 week if symptoms persist or worsen. Thought process of why something is done: The diagnosis is based on the clinical presentation and examination findings. The management plan is based on current guidelines for URTI.

History: [history of presenting complaint, onset, course, duration, previous treatments or interventions, triggers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [patient's ideas, concerns, expectations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [red flags] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [psychosocial background] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [allergies, past medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Examination: [vitals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [systems] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [chaperone] (optional - only if mentioned) (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Diagnosis: [working diagnosis or differential] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) Plan: [shared management plan - doctor's share, patient's share] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [safety netting and follow up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.) [thought process of why something is done] (optional) (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.)

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