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Clinic Notes

Outpatient consultation documentation template for new and follow-up appointments.

Purpose

Clinic notes document outpatient consultations, providing a record of the consultation, clinical findings, decisions made and the agreed management plan. They are shared with the GP and other members of the clinical team.

Key Components

  • Clinic type: new / follow-up
  • Referring clinician and reason for referral
  • Presenting complaint or review reason
  • History and background
  • Examination findings
  • Investigation results reviewed
  • New investigations requested
  • Assessment and diagnosis
  • Management plan and options discussed
  • Patient's wishes and shared decision-making
  • Safety netting and red flag advice given
  • Follow-up arrangements
  • Copy to: GP and relevant clinicians

Documentation Tips

  • Note whether this is a new or follow-up appointment
  • Document shared decision-making clearly
  • Record safety-netting advice given to patient
  • Note the patient's understanding and agreement with the plan
  • Confirm copy recipients at the end of the letter
Reminder: Always date, time and sign all clinical entries. Include your name and GMC/NMC number.
Template
DATE: ___________  TIME: ___________
CLINIC: _______________________________
CONSULTANT: ___________________________
CLINICIAN SEEN BY: _____________________

PATIENT: ______________________________
DOB: _____________  NHS No: ____________

APPOINTMENT TYPE: New / Follow-up
REFERRAL FROM: ________________________
REASON FOR REFERRAL: __________________

TODAY'S CONCERNS:
[Main reason for this appointment]

HISTORY:
[Relevant history and background]

EXAMINATION:
[Relevant findings]

INVESTIGATIONS REVIEWED:
[Results discussed]

NEW INVESTIGATIONS:
[Tests requested today]

ASSESSMENT:
[Diagnosis / differential / progress]

MANAGEMENT PLAN:
1.
2.
3.

PATIENT INFORMATION:
Condition explained: Yes / No
Options discussed: Yes / No
Patient agrees with plan: Yes / No
Safety-netting advice given: Yes / No

FOLLOW-UP:
Return in: _____________________________
With: _________________________________
If concerned contact: __________________

COPY TO: GP, ___________________________

SIGNATURE: ____________  DATE: _________
NAME (print): __________________________