Consultation Note Template
A structured consultation note captures the full clinical encounter from presenting complaint through to management plan. Use this template for specialist outpatient consultations or let WhiteFieldHealth generate it from a recording.
WhiteFieldHealth
Built for reviewable clinical documentation, not generic AI output.
When to use a consultation note
Consultation notes are used for specialist outpatient encounters, new patient assessments, and any clinical encounter where a comprehensive record of the presenting complaint, examination, diagnosis, and plan is required. Unlike SOAP notes, which are common in primary care, consultation notes tend to be more detailed and specialty-specific. This format is suitable for dermatology, rheumatology, respiratory, and other outpatient specialties where a structured narrative aids both clinical communication and medicolegal defensibility.
Worked example: Dermatology consultation
Presenting Complaint
42-year-old female referred by GP for assessment of a persistent, pruritic rash on bilateral lower legs of 3 months’ duration. Not responding to emollients or OTC hydrocortisone 1% cream.
History
Rash first noticed in December 2025, initially affecting the left shin and spreading to both lower legs over the following weeks. Characterised by intense itching, worse in the evening and after hot showers. No preceding illness, new medications, or contact exposures. No joint pain, nail changes, or oral lesions. Past medical history: asthma (well controlled on salbutamol PRN), no previous skin conditions. Medications: salbutamol 100 mcg inhaler PRN, cetirizine 10 mg OD (self-initiated for itch). Allergies: NKDA. Family history: father has psoriasis. Social: non-smoker, works as a secondary school teacher. No recent travel.
Examination Findings
Well-demarcated, erythematous plaques with silvery-white scale on bilateral anterior shins, largest measuring 6 cm × 4 cm on the left leg. Auspitz sign positive. No plaques on elbows, knees, or scalp on examination today. Nails: mild pitting of 3 fingernails on the right hand, no onycholysis. No joint swelling or tenderness. No lymphadenopathy. Remainder of skin examination unremarkable.
Diagnosis
Chronic plaque psoriasis — mild to moderate, predominantly affecting the lower limbs. Differential considered and excluded: nummular eczema (less likely given well-demarcated borders, Auspitz sign, and family history), tinea corporis (no central clearing, scaling pattern inconsistent).
Management Plan
1. Calcipotriol/betamethasone dipropionate gel (Enstilar) OD for 4 weeks to active plaques, then weekends only for maintenance. 2. Continue regular emollient (Cetraben) BD to all affected areas. 3. Patient education: explained chronic nature of psoriasis, trigger avoidance (stress, skin trauma), and importance of regular moisturising. Written information leaflet provided (BAD patient information). 4. Bloods not required at this stage. 5. Follow-up in dermatology clinic in 8 weeks to assess response. 6. If inadequate response at review, consider phototherapy referral or escalation to systemic therapy. 7. Letter to GP with above plan — no GP prescribing changes needed at this time.
Tips for effective consultation notes
Use specialty-specific language
Describe findings using the terminology expected in your specialty. For dermatology, include morphology, distribution, and named signs.
Document the examination systematically
Follow a consistent order for examination findings so that colleagues can quickly locate specific information on re-reading.
State your differential explicitly
List the diagnoses you considered and briefly explain why you ruled them out. This demonstrates clinical reasoning and aids future clinicians.
Include patient education
Document what you explained to the patient, including written materials provided. This supports shared decision-making and medicolegal clarity.
Communicate back to the referrer
End with clear instructions for the GP: whether prescribing changes are needed, what to monitor, and when to re-refer if the plan is not working.
How WhiteFieldHealth generates consultation notes automatically
WhiteFieldHealth listens to the specialist consultation, identifies clinical findings, diagnoses, and management actions, and structures them into a consultation note. Specialty-specific terminology is preserved and drug mentions are cross-referenced with BNF data through our AI medical scribe pipeline. The clinician reviews and approves the draft before it becomes part of the patient record.
Works across specialties for UK clinicians and hospital outpatient departments. See pricing for plan details.
Generate consultation notes automatically
Record specialist consultations and get structured, reviewable notes with examination findings and management plans in seconds.