Clinical notes that help at the next appointment

You open a patient’s record just before their appointment. The last note describes a busy consultation, but finding the agreed next step takes longer than expected. A few deliberate writing habits can make that moment easier for you and the colleague covering your leave.

The RACGP’s record-quality guide connects accurate, complete records with informed decisions and continuity of care. It also recognises that good record keeping needs time and support within the practice. Read the RACGP introduction to quality health records.

Give the reader a route through the visit

Use your profession’s documentation requirements and your clinic’s agreed structure. Within that structure, make these parts easy to locate:

• The reason for today’s visit and the patient’s priorities.
• Relevant information reported by the patient or another person, with its source identified.
• Your findings, assessment and reasoning.
• What was discussed, agreed or left unresolved.
• The next action, who will take it and the agreed timing.

Clear, objective language and relevant information about the person’s goals are among the Australian Commission’s documentation principles. Its guidance also emphasises timely entries that accurately reflect the care provided. Read the Commission’s documentation guidance.

Make the next step specific

Here is a fictional example of an administrative detail within a clinical note:

Jordan would like appointments that fit around school pickup. Reception to offer the agreed review appointment using the contact preference recorded today. Jordan will bring the report discussed at this visit. Clinician to review it when received.

This extract is only an example of recording arrangements. The clinical assessment, timing and care decisions belong in the full note and depend on the consultation.

When reading your own draft, look for loose ends. If you wrote “letter needed”, can you name the recipient and purpose? If you wrote “review later”, did you record the timing actually agreed? A named action gives the next reader something they can follow.

Check the parts that are easy to carry forward

Templates can give you a useful starting point. Before signing, read any carried-forward text as carefully as the new entry. Check the visit date, names, pronouns, laterality where relevant, and any statement about what happened today. Remove unused prompts and resolve contradictory statements.

Give reported information a clear owner. “Patient reports…” and “Referral dated…” help a colleague understand where a detail came from. If something remains uncertain, record that uncertainty and the plan for clarifying it.

Try a small review with a colleague

Choose one fictional note or an authorised example within your practice’s review process. Ask a colleague to find the patient’s priority, the reasoning and the next action. Notice where they pause or need to ask you a question.

Use those pauses to improve one template heading or one writing habit. A heading such as “Agreed next steps” may be enough to make an existing template more useful. Keep any extra fields that your profession or clinic requires.

Where the next action passes to another clinician, use the same detail in a useful clinical handover.

Sources checked on 6 October 2026.