General practice patient records: what a ten-minute visit should leave behind
· 6 min read
A general practice visit is short. In a busy outpatient clinic it is often ten minutes or less, and a good part of that goes on the patient describing the problem. Whatever gets written down has to be written quickly, and it has to be useful to whoever opens the record at the next visit, which may be months away.
This post is about what that record needs to hold. None of it is new to a careful doctor. The point is to be clear about which parts belong to the visit, which belong to the patient, and what goes missing when the two are mixed up.
Two kinds of information
Everything in a general practice record falls into one of two groups.
- What belongs to the visit. Today's readings, the complaint, the diagnosis, the prescription, the follow-up date. It is true of this visit and is never rewritten afterwards.
- What the patient carries between visits. Allergies and long-term conditions. It is true every time the patient walks in, whoever is seeing them.
Paper tends to put both in the same place: the visit note. An allergy written on a slip from last year is technically recorded, but nobody will find it in a ten-minute visit. So the question gets asked again from memory, and the answer depends on the patient remembering.
Information the patient carries should be kept on the patient and shown at every visit without anyone having to look for it.
Vitals are only useful next to the last reading
A blood pressure of 142/90 says little on its own. Next to the two readings before it, it says a good deal more.
| Reading | 2 January | 3 February | 14 April |
|---|---|---|---|
| Blood pressure | 150/94 | 136/88 | 142/90 |
| Pulse | 82 | 80 | 84 |
| Weight | 88 kg | 87 kg | 86 kg |
A paper file holds the same three readings, but on three separate pages, and comparing them means leafing back while the patient waits. Three habits make the readings worth keeping:
- Record them every visit, in the same place. A reading that is sometimes in the margin and sometimes in the note can't be lined up later.
- Record the unit you measured in. °F or °C, mg/dL or mmol/L. A number with no unit is a guess for the next reader.
- For blood sugar, record whether it was fasting or random. The same figure means different things, and nobody will remember which it was.
Write the diagnosis the same way each time
"HTN", "Hypertension" and "High BP" are the same diagnosis written three ways. A person reading the file sees that at once. Software doesn't, and neither does anyone trying to count how many patients with hypertension the clinic sees.
Free text is the right tool for a diagnosis in a short visit. It is fast, and it lets you say exactly what you mean, such as "essential hypertension, poorly controlled". It only needs one thing added to it: a way to reuse the wording you chose last time, so the same condition is spelled the same way across the clinic.
A visit often has more than one diagnosis. The patient who came in for headaches may also be due a diabetes review. Each should be written as its own entry, not joined into one line.
A prescription the patient can follow
A prescription is read by three people: the pharmacist, the patient, and you at the next visit. Each line should answer the same questions for all three.
- What. The medicine, its strength and its form: Amlodipine 5 mg, tablet.
- How often. Many clinics write this as a dose pattern. 1+0+1 means one in the morning, none in the afternoon and one at night. 1+0+0 is morning only, and 0+0+1 is night only.
- When. Before or after food.
- By which route, when it isn't obvious.
- For how long. The number of days.
- How many. The quantity follows from the rest: 1+0+1 for five days is ten tablets. Writing it down saves the pharmacist the arithmetic and gives the patient a number to check.
When each of those is a separate field and not one handwritten line, the prescription prints the same way every time, and last month's prescription can be read at a glance next month.
Checking a prescription against allergies
The allergy list earns its place at the moment a prescription is written. If a medicine you are about to prescribe has the same name as something on the patient's allergy list, that should be pointed out before the prescription is finished.
A name match has a limit, and it is worth being plain about it. A brand name doesn't say what the medicine contains, so matching by name will catch "ibuprofen" against an ibuprofen allergy, but it won't recognize a brand that contains it. A warning like this is a prompt to look again. It doesn't replace reading the allergy list, which is the reason the list should be on screen while you prescribe.
Leave the visit as it was
Once a visit is finished, it should stay as it was written. If something was recorded wrongly, the correction should be added with its own date and the original left readable. At the next visit you want to know what was actually measured and prescribed on the day, not a version that was tidied afterwards.
The follow-up closes the loop
A reading only becomes "the last reading" if the patient comes back. Set the follow-up date before the visit ends, while the patient is still in the room, and look at who is due and overdue every day. For a patient who is overdue, a short WhatsApp message from the clinic's own number is usually the quickest way to reach them.
If you keep records on paper today
Most of this is what a careful doctor already does on paper. What paper can't do is put the last reading beside today's, show the allergy list at every visit without being asked, or spell a diagnosis the same way across a thousand files.
That is what KeepPulsing General Clinic is built around. Vitals are recorded at each visit with the last reading beside them, in the units you took them in. Allergies and long-term conditions are kept on the patient and shown every time. Diagnoses are free text, with suggestions from what your clinic has written before. Each medicine is written as strength, form, frequency, food timing, route and days, with the quantity worked out from frequency and days and open to change. You are warned when a medicine's name matches a recorded allergy. The prescription prints on your own letterhead, and a finalized visit can't be changed, only amended. It keeps the clinic's records and workflow; it does not give clinical advice.