Effective clinical documentation is essential for general practitioners to ensure accurate patient care and seamless communication between healthcare providers. The NHS GP Consult note is a critical document that requires precision and clarity. In this guide, we will walk through the proper way to write and format a consult note, using a structured template. We will also explore how AI medical scribes like Notis AI Medical Scribe can automate and enhance this process, saving valuable time for practitioners.

Correctly Writing and Formatting NHS GP Consult Notes

Template Breakdown

The NHS GP Consult note is typically structured around the SOAP (Subjective, Objective, Assessment, Plan) format. This format ensures that all relevant patient information is captured efficiently and systematically.

Subjective Section

This section captures the patient's perspective, including their symptoms and concerns. For example:

History:

• Chief Complaint: "F2F seen alone. Reason for visit: Follow-up for persistent cough and fatigue."

• Patient's Experience: "The patient reports a persistent cough for the past three weeks, accompanied by fatigue and occasional shortness of breath."

• ICE (Ideas, Concerns, Expectations): "The patient is concerned about the possibility of a chest infection and expects to receive treatment to alleviate symptoms."

• Relevant History: "No red flag symptoms such as hemoptysis or significant weight loss."

• Risk Factors: "History of smoking (10 pack-years)."

• Past Medical History (PMH): "Hypertension, managed with lisinopril."

• Drug History (DH): "Currently taking lisinopril. No known drug allergies."

• Family History (FH): "Father had COPD."

• Social History (SH): "Lives alone, works as a teacher, quit smoking 5 years ago, occasional alcohol use, no recent travel."

Objective Section

This section notes the results of the physical examination and any vital signs.

Examination:

• Vital Signs: "T 37.2°C, Sats 96%, HR 78 bpm, BP 130/85 mmHg, RR 18 breaths/min."

• Physical Examination: "Chest examination reveals bilateral wheezing. No other significant findings."

Assessment Section

Here, the clinician interprets the subjective and objective findings to make a diagnosis.

Impression:

• Primary Diagnosis: "Persistent cough. Likely diagnosis: Bronchitis."

• Differential Diagnosis: "Asthma exacerbation."

Plan Section

This section outlines the plan for further investigation, treatment, and follow-up.

Plan:

• Investigations Planned: "Chest X-ray to rule out pneumonia."

• Treatment Planned: "Prescribe a short course of oral corticosteroids."

• Referrals: "None at this time."

• Follow-Up Plan: "Review in 2 weeks or sooner if symptoms worsen."

• Safety Netting Advice: "If symptoms worsen or new symptoms such as high fever or chest pain develop, call GP or 111. In case of severe breathing difficulty, attend A&E or call 999."

Enhancing Documentation with AI Medical Scribes

Creating comprehensive and accurate clinical notes can be time-consuming. This is where AI medical scribes like Notis AI Medical Scribe come into play, offering significant improvements in efficiency and accuracy.

Automating the Documentation Process

Notis AI Medical Scribe utilizes advanced voice-to-text technology to transcribe patient interactions into structured SOAP notes. This automation can reduce the time spent on documentation by up to 80%, allowing general practitioners to focus more on patient care.

Key Benefits for General Practitioners

By integrating with a familiar interface like WhatsApp, Notis eliminates the need for additional software, making it accessible and easy to use. Its high accuracy in transcription and support for multiple languages ensure that medical notes are precise and comprehensive.

Furthermore, Notis offers features such as smart search and retrieval, allowing practitioners to access patient history efficiently. This capability, combined with document and image analysis, enhances the overall documentation process.

In conclusion, leveraging AI medical scribes like Notis can transform the way general practitioners handle patient documentation, saving time and improving accuracy. By streamlining the creation of NHS GP Consult notes, healthcare providers can enhance patient care and reduce administrative burdens.