A private GP procedure note template that sets out what belongs in each section, ready to adapt to your own clinic.
01Procedure 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 procedure note, ear irrigation
1Indication
Symptoms, examination findings and any attempt to soften the wax first.
2Consent
How consent was taken, and the risks, benefits and alternatives discussed.
Whether written consent is on the record, with its date.
3Procedure
Method and equipment used, and both ears examined before and after.
Patient identity and side confirmed before starting.
4Findings
What was found or measured, in terms another clinician could act on.
5Complications
Any complication, or a record that there were none.
Anything that did not go to plan, and what was done about it.
6Aftercare and follow-up
Aftercare advice given, verbally and in writing.
Follow-up arranged, and what should prompt the patient to get in touch sooner.
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.
01Procedure note
SignedAI-assisted, edited by the clinician
Patient
Invented patient, for illustration
Clinician
[Clinician name]
Consultation
In person
Private GP procedure note
1Indication
Right ear blocked despite one week of softening drops. Wax occluding the canal on examination.00:50
2Consent
Completed by the clinician from the record.
3Procedure
Right ear irrigated. Patient identity and side confirmed before starting.03:15
4Findings
Canal clear after irrigation. Tympanic membrane intact and normal.06:40
5Complications
Completed by the clinician from the record.
6Aftercare and follow-up
Keep ear dry for 48 hours. Advised to call if pain or discharge.07:30
Questions
What goes in a private GP procedure note?
Indication, Consent, Procedure, Findings, Complications and Aftercare and follow-up. 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.
