---
title: "Treatment notes: what to record"
description: What to include in initial and follow-up treatment notes, with a checklist you can turn into a HealthBank note template.
image: https://help.healthbank.io/hubfs/Help%20article%20graphics/Home/help-centre-share.png
---
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October 20, 2026
# Treatment notes: what to record
## What to include in initial and follow-up treatment notes, with a checklist you can turn into a HealthBank note template.
Good notes protect you and your client, and make every follow-up faster. Use these checklists to build your note templates in HealthBank once, then reuse them for every client.
**Initial consultation**
- Personal details, contact information and emergency contact (already in the client's profile)
- Referral source: GP, specialist or self-referred
- Medicare, private health, DVA or pension details
- Reason for visit and goals
- Medical, family and social history
- Medications and supplements
- Test results/reports
- Wearable data
- Allergies and intolerances
- Relevant measurements and test results (link pathology from their Health Record)
- Lifestyle: sleep, stress, energy, exercise, alcohol, smoking or vaping, work
- Assessment and review of body systems, as relevant to your profession
- Food intake/diet recall
- Advice, education and resources given
- Plan, referrals and next appointment
**Follow-up consultation**
- Progress since the last session
- Changes made and goals achieved
- Changes in symptoms, measurements or results
- Barriers to change
- Updated goals and plan
- Resources given and referrals made
- Next appointment
**Dietitians:** add diet history, symptom diary review and, where relevant, body composition (weight history, BMI, waist-to-hip ratio).
**Keep records for at least seven years** (longer for children). \[Robbie to confirm: the retention rule to quote, as it varies by state and profession.\]
\[Robbie to confirm: should we mention the AI scribe and visit summaries here? There's no help article for them yet.\]
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