Neptune "Consultation Template".

This is my medical text Consultation template which can be bought from this website (pay and download) . I have used it for the past 10 years.

This is priced at just £50 which is far cheaper than AI Scribe templates in 2026. The BMA has Medico-legal Traiing Courses. 

WRITING GOOD MEDICAL RECORDS 

There is a skill in writing good medical records to protect oneself legally and minimise risk of Prosecution. I have written this using logical reasoning; and  my skills as a GP Trainer. One observes and learns this from good quality hospital letters that we receive all the time. 

The first line of each  entry should state  for the GMC, Court and Solicitors; that you have reviewed the past records, medication and allergies. Otherwise they will argue that you never bothered to review these items and you are a bad doctor.

The criticism is that you did not write it at the time ;so you did not review that past history and you are lying. You are not allowed to edit the wording three months later after a Complaint is filed or a patient has died; as this is considered as falsifying the medical record. You must write it at the time you saw or spoke to the patient. 

The GMC Investiators  look for such falsification of the medical records. The computer systems log every key stroke and button pressed as part of the Audit process.I

I think that this is a false critisicm  as every Doctor I know always reviews this past information but does not have the time to write everything down of their thought process.

The second line of your entry (in logical order)  should state some of the past diagnoses as written evidence that you have reviewed the medical records e.g. Known past Diabetes (2022), Asthma (2023), Lung Cancer (2025), Depression (2025).

Then write the History, Examination findings, Differential Diagnosis, Investigations and Management Plan in this logical order. 

My Consultation Template makes this easy to record and saves a lot of time; about an hour a day.

It would be illogical and incorrect to write the Management Plan first and then the History. It is incorrect to write the BP in the History section as it is part of the Examination. Such entries indicate disordered poor thinking so write in each section in logical order.

Doctors and Nurses are "trained observers" and we    observe patients all the time; but we do not have the time to wrtite everything down.  

It is important to record positive and negative findings for medico legal protection. It is important to frequently record BP, pulse rate, Oxygen Saturation, Temperature and Respiratory Rate.

Save the entry and check it for typing errors. It is a good idea to "Save" it a few times and recheck it.

The General  Physical Examination findings are very important e.g. NO cyanosis/ pallor/ Jaundice/ Stridor/ SOB/ distress. My Consultation Template makes this easy to record and saves a lot of time. 

Ideally in every record you would write the BP, Pulse, Oxygen saturation, Respiratory rate, Temperature etc. as part of the NEWS (National Early Warning Score ) SCORE in the UK. This score is important for Paramedics, Nurses and Doctors in the UK to record in the medical records. 

If you speak to a Paramedic on the phone from an Ambulance callout;  ensure that you write down in your notebook and record on computer the BP, Pulse, Temperature etc. as this will help to protect you legally and justifies why you agree with the Paramedic not to send the patient into hospital that day; as there is no acute emergency problem.. 

For the GMC you  needs to write your thought process and possible diagnoses; in logical order. e.g. Numb feet so check HbA1c and B12 level. 

The more detail you write the better. I am not keen on very  concise medical records. 

Such good medical records help to protect the whole team of Doctors and Nurses from Complaints and Prosecution. 

You need to write your Management Plan correctly 
e.g. To review with  blood test results in 2 weeks.
e.g. Review with Xray result in 2 weeks. 
e.g. Refer Rheumatology – explained NHS waiting time of 3 months

You need to write any Admin. Problems or errors from that day  also 
e.g.  EMIS crashed today so is not saving data properly today.  

e.g. Printing error so Prescription printed again. (2 copies of the drug on computer).
e.g. Another patient has collapsed in reception so I abandoned this consultation.Patient to book again.
e.g. EPS error so Prescription is not processing on computer today. Patient to contact our reception  tomorrow for this.
e.g. Patient  racist, swearing and abusive. Using the F*** word. To send warning letter. Pressed the red           emergency button – called our Practice Manager to help calm the patient. 
e.g. Used Romanian Interpreter with “Language Line”  Service.

e.g. Patient is going abroad  on holiday so delay the 2WW urgent Cancer referral until he returns in June 2020.

Whole phrases  or  paragraphs of text can be quickly copied and then inserted (pasted) and edited into a medical record to make a good quality entry  efficiently. It has a simple text format. It is a memory aid (aide memoire) for recording the important aspects of a Consultation. Then edit the text as needed. 

Just keep this file open and downsized at the bottom of the computer screen.

Then maximise it several times to copy the desired text into the patient record.

UK Doctors are very busy .Moving to  a system of 15 minutes per patient instead of 10 minutes per patient is beneficial. This enables 5 minutes for taking the history, 5 minutes for examining the patient and 5 minutes for writing a very good text entry into the medical record.

It is very beneficial to write an Admin. note in the computer record even if you have not phoned or seen the patient . Also to write the letters and Pathology results you have reviewed with the dates. Here is a fictional example:

e.g. Past notes, medication & allergies reviewed. Known past Diabetes, Lung Cancer, Schizophrenia 2024. Oncology letter dated 1/3/18revewied - started Chemotherapy and has side effects. Says has leg pain so Cocodamol was started last week on 1/4/18 . SE were  explained. Blood results dated 30/3/18 revewed - FBC, U+E, LFT ,TFT normal. ECG dated 15/3/18 normal - reviewed.A+E letter dated 5/3/18 reviewed - nil acute. 

Such an entry helps to protect the whole team legally. 

There is no need to rewrite all the  letters or notes ; just to state that letter dated 1/3/20 reviewed. This letter and blood results  then must be brought into the legal argument in Court. This helps to defend oneself legally.

Here are a  fictional example of the text entry that can be quickly created using this template:

Example - For nearly every adult patient the following text can be quickly copied  into the medical record and edited as necessary from paragraphs 3,10 and 11 from the template:

PMH + DH reviewed. Medications & Allergies reviewed. Recent entries, Pathology results  and hospital letters reviewed from the past 6 months . 

Speaks full sentences; no anaemia, stridor, grunting, cyanosis, nasal flaring, use of accessory muscles, or pallor or jaundice or distress ; pink on air; no symptoms of calf redness or DVTs. No ankle oedema.  Resp. Rate 20/min. Relaxed and comfortable at rest. Systemically well. 

MSE- clean and tidy appearance; good logical thought; no strange  behaviour. Good eye contact. Relaxed, calm. Normal rate  and volume of speech. No ideas of self harm or harming others. Can retain, remember and recall information today so has mental capacity. 

I think writing such negative findings is medico legally protective for the doctor. The more you can write  as a doctor the better. A common criticism is poor record keeping by the doctor with insufficient detail. Frequently recording the BP, pulse, Oxygen saturation , temperature and respiratory rate will also help  protect the doctor or Nurse ;  from criticism of poor practice For children frequently record the pulse rate , heart rate , temperature and respiratory rate.

For over 10 years consultations have been videoed in the USA and I think this has helped to protect Clinicians legally aganist Complaints and Prosecution. I think this will have saved money for the Clinics in the USA as we know there is a high rate of prosecutions there. I think that patients are often malicious, vindictive liars and we need to have really good technical and scientific medical  records to defend ourselves legally. 

This is not the system in the UK - in the last 3 years AI Scribe software is being used here such as Heidi.