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Show what has changed since the previous review, how the person has responded, and what the next plan is.
Structure
Adapt headings to local policy, specialty, encounter type, and record requirements.
Anchor the note to the previous review and describe new symptoms, events, adherence, function, concerns, and relevant changes since then.
Record response, adverse effects, current observations or results, progress against goals, and the updated assessment with remaining uncertainty.
State what continues, changes, stops, or escalates, with monitoring, follow-up, ownership, timing, and revised safety-netting.
Document-specific checks
Distinguish genuinely new information from copied history and ensure the interval and comparison point are clear.
Verify trends, measurements, medicine response, adverse effects, goal status, and any deterioration or new risk requiring action.
Remove obsolete actions, reconcile the current plan, assign pending work, and document the next review or discharge criteria.
Review
Remove unsupported detail and confirm that attribution, chronology, negatives, and uncertainty match the encounter.
Verify medicines, doses, measurements, diagnoses, risk statements, investigations, and follow-up instructions.
Make the requested action, owner, urgency, and handover information unambiguous where they apply.
Workflow
Select the template that matches the documentation purpose before generating the draft.
Use encounter content to populate the structure, then correct omissions, wording, and section placement.
Only move the document into its destination after the responsible clinician has completed the review.
Continue exploring
These pages add the operational, documentation, and trust context around this topic.
Next step
Generate a structured draft, then verify every material detail before it becomes part of the clinical record.