Templates, Clinical notes, Private GP

Private GP initial consultation note template

A private GP initial consultation note template that sets out what belongs in each section, ready to adapt to your own clinic.

01Initial consultation note

TemplatePrivate GP

Patient: [Name]
Date of birth: [Date]
Record number: [Number]
Clinician: [Name, registration number]
Consultation: [Date and time], [in person or video]

Private GP initial consultation note

1Presenting complaint

The reason for the visit, in the patient's own words where they are useful.
How long it has been going on.

2History of the presenting complaint

Onset, course and what makes it better or worse.
What the patient has already tried, and what they hope this visit achieves.

3Past history, medicines and allergies

Relevant past medical and surgical history.
Current medicines, including anything bought over the counter.
Allergies and the reaction each one caused, or a record that none are known.

4Social and family history

Occupation, smoking, alcohol and anything else relevant to the complaint.
Family history where it changes risk or management.

5Examination

Temperature, pulse, blood pressure and oxygen saturation where relevant.
Findings on examination of the system involved, including relevant negatives.

6Impression

The working diagnosis, and the differentials still being considered.
The clinician's reasoning, in a sentence or two.

7Plan

Investigations requested, and who follows up the result.
Treatment agreed, as prescribed in the prescribing record.
Any referral, and whether a letter to the registered GP is needed.

8Safety-netting

What should prompt the patient to get back in touch, and how.
When the next review is due.

How the Wai scribe fills it

The same note, written from an invented consultation.

Each line links to the moment in the transcript it came from, and the clinician reads, corrects and signs the note before it is filed.

01Initial consultation note

SignedAI-assisted, edited by the clinician

Patient: Invented patient, for illustration
Clinician: [Clinician name]
Consultation: In person

Private GP initial consultation note

1Presenting complaint

Cough for three weeks, not improving.00:42

2History of the presenting complaint

Worse at night. Clear sputum. No haemoptysis, no breathlessness.01:30

3Past history, medicines and allergies

Completed by the clinician from the record.

4Social and family history

Completed by the clinician from the record.

5Examination

Chest clear bilaterally. SpO2 98% on air.04:10

6Impression

Likely post-viral cough. No red flag features.05:05

7Plan

Review in three weeks. Chest X-ray if persisting.05:40

8Safety-netting

Advised to call the same day with haemoptysis or breathlessness.06:20

Transcript

What was said, and the line of the note it became.

00:42I've had this cough for about three weeks and it's not shifting.Cough for three weeks, not improving.
01:30It's worse at night, a bit of clear phlegm, no blood, and I'm not short of breath.Worse at night. Clear sputum. No haemoptysis, no breathlessness.
04:10Your chest sounds clear on both sides and your oxygen is ninety-eight percent.Chest clear bilaterally. SpO2 98% on air.
05:05This looks like a cough that's lingering after a viral infection.Likely post-viral cough. No red flag features.
05:40If it's still there in three weeks we'll get a chest X-ray.Review in three weeks. Chest X-ray if persisting.
06:20If you cough up blood or get short of breath, call us that day.Advised to call the same day with haemoptysis or breathlessness.

Wai writes this note while you talk to the patient

The note, letters and referrals from one consultation, in your own structure, held for your signature. Wai keeps this note current, versioned and signed off for you.

Request a demo Email us

Questions

What goes in a private GP initial consultation note?

Presenting complaint, History of the presenting complaint, Past history, medicines and allergies, Social and family history, Examination, Impression, Plan and Safety-netting. Each section on this page lists what belongs in it, written for private gp.

Is the worked example a real patient?

No. The consultation is invented for this page, and no real patient or record is used.

Does the scribe sign the note?

No. The scribe drafts the note from the consultation, and the clinician reads, corrects and signs it, with the time and the change from the draft kept on the record.

Can we use our own note structure?

Yes. Your clinic's own sections are set up once, and the scribe writes each consultation into them.

The initial consultation note in other specialties

All clinical notes

Come back to the note, written and ready to sign.

See the Wai scribe write a private GP initial consultation note on your own structure, in a 15 minute video call.

Request a demo Email us

Below it is the same note filled in by the Wai scribe from an invented consultation, line by line, for the clinician to read and sign.

Updated 16 October 2026. Written by our clinical team, generic by design, with no dosing advice.

Private GP initial consultation note

1Presenting complaint

2History of the presenting complaint

3Past history, medicines and allergies

4Social and family history

5Examination

6Impression

7Plan

8Safety-netting

How the Wai scribe fills it

Private GP initial consultation note

1Presenting complaint

2History of the presenting complaint

3Past history, medicines and allergies

4Social and family history

5Examination

6Impression

7Plan

8Safety-netting

Questions

The initial consultation note in other specialties

Further reading

Come back to the note, written and ready to sign.