GP Communication and Clinical Advice: How to Document the Follow-Up Loop

"GP Notified" Is Not a Complete Record

When a GP or other authorised clinician is contacted, the record should let the next worker understand why contact was needed, what information was provided, what advice was received, and who is responsible for carrying out and reviewing the next steps.

The progress note should summarise relevant care information. Formal orders, prescriptions, medication charts, consultation records, and care plan updates must still be completed in their designated systems.

Prepare a Clear Clinical Picture

Before contact, gather the person's baseline, current observations, onset and pattern of change, relevant measurements taken within scope, current care instructions, recent events, and the person's goals or concerns. Use the provider's clinical communication framework where one is required.

What to Document

Reason and urgency

Describe the change or question prompting contact and any immediate safety action already taken.

Contact attempts

Record the service or clinician contacted, date and time, method, whether contact was successful, and the escalation used if a response was delayed.

Information and advice

Summarise the relevant information shared and record advice accurately, attributing it to the clinician. Seek clarification when an instruction is unclear rather than interpreting it independently.

Implementation and review

Identify authorised changes, monitoring parameters, review time, records updated, person or representative communication, and the worker accountable for follow-up.

Example GP Communication Note

"At 10:15 AM, Helen reported burning discomfort when passing urine and requested medical review. Temperature and other observations completed by RN under clinical procedure. RN contacted Helen's GP clinic at 10:30 AM and provided the current symptoms, observations, usual presentation, and relevant history. GP returned the call at 11:05 AM and arranged same-day assessment, with interim monitoring instructions documented by RN in the clinical plan. Helen agreed to the appointment and asked that her daughter be informed. Daughter contacted at 11:20 AM. Team leader assigned to confirm transport and record the consultation outcome."

After the Appointment

Close the loop by documenting the assessment outcome, authorised changes, prescriptions or tests arranged, updated care instructions, communication with the person, and the next review. If results or a clinician response remain outstanding, make that pending item visible with an owner and due point.

Common Coordination Failures

• Multiple contact attempts occur but only the successful call is recorded.
• The advice is documented without the clinician's name or time.
• A new instruction is mentioned in handover but not added to the approved care record.
• The person is not told what will happen next.
• Tests, results, prescriptions, or review appointments remain open without an owner.

The same accountability principles apply to other external clinicians. See the guide to allied health referral tracking and follow-up.

This article was written by AccuNote's Clinical Coordination Team for general documentation education. Providers should follow clinical governance, privacy, consent, prescribing, and emergency escalation requirements.