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General Practice

GP consultation documentation, referral letters and chronic disease management records.

Documentation Overview

GP documentation covers the breadth of primary care — from acute presentations to long-term condition management. Clear, searchable records support continuity of care across the entire practice team and across care settings.

Key Documentation Standards

  • SOAP or problem-oriented format for consultation notes
  • Read/SNOMED codes applied to all diagnoses
  • Medication changes with explicit reason recorded
  • Safety-netting documented for every uncertain consultation
  • Referral letters include all relevant background and specific question
  • Chronic disease reviews follow structured QOF/local templates

Common Documentation Scenarios

  • Acute undifferentiated illness — history, examination, safety net, follow-up
  • Chronic disease review — structured template, targets, medication review
  • Telephone/video consultation — note modality, limitations documented
  • 2-week-wait referral — clinical features, red flags documented
  • Sick note (Med 3) — diagnosis, functional impact
  • Multimorbidity — problem list management, polypharmacy review

Relevant Templates

Quick Reference
GP CONSULTATION DOCUMENTATION
=========================================
REASON FOR CONSULTATION:
[PC in patient's words]

HISTORY:
Onset / Duration / Character
Severity / Radiation / Associations
Relieving / Aggravating factors

RED FLAGS SCREENED:
□ Relevant red flags excluded / present

EXAMINATION:
[Relevant findings or "No examination — telephone"]

IMPRESSION:
[Diagnosis or working diagnosis]

MANAGEMENT:
□ Investigations
□ Prescription (dose, duration, reason)
□ Referral (urgency, reason)
□ Self-care advice

SAFETY NETTING:
□ Patient advised to return if [X]
□ 111 if urgent

FOLLOW-UP:
□ Review in ___ days/weeks
□ Awaiting: _______________
Specialty-specific: Always refer to your hospital's specialty-specific documentation policies and national guidelines.