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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).