The notes are done before I leave now, and they are better than the ones I used to write from memory at nine at night.
About the clinic
A private GP practice in central London with three doctors and a small reception team. As in most primary care, the appointment was the shorter part of the day. The notes, referral letters, results and patient messages that followed each visit took longer than the visits themselves.
Opportunity
Most of the documentation was being done after hours. Notes written up in the evening from memory, referral letters held over to the weekend, blood results sitting unread in an inbox while patients waited to hear back. It is rarely the medicine that makes the job feel relentless. It is the typing that comes after it. And a note written from memory late at night is also the only thing standing behind a decision if it is ever questioned.
“I used to finish my notes at home, once the children were in bed,” the lead GP said. “I had stopped noticing it was unusual.”
Solution
For six weeks the clinic ran Wellness A\ alongside its existing records system. It listened to each consultation and drafted the note in the clinic’s own format. The difference from a tool that only transcribes was in what it captured. Rather than a tidy summary of what was said, it produced a structured clinical record, the history, the examination, the reasoning, the advice given and the safety-netting, written to the standard a complaint or a claim would later be judged against.
Where recognised guidance applied, it was referenced in the record and the draft prompted for the things a complete note should contain. The judgment stayed with the doctor. The record simply reflected all of it. It then prepared the referral letter, the results explanation and the patient message. Every word remained the clinician’s, and nothing was saved or sent until a doctor had read and approved it.
Key use cases
- A defensible record, not just a transcript. The note sets out the history, reasoning, advice and safety-netting in the clinic’s format, structured the way a record needs to read if it is ever reviewed.
- Guidance referenced, not enforced. Where recognised guidance applies it is noted in the record, so the documentation is complete while the decision stays the doctor’s.
- Referral letters. Drafted straight from the consultation rather than held for the weekend, which is where the backlog used to build.
- Results. Patients receive a plain explanation of their bloods, written for the doctor to approve, instead of a line in a portal they cannot read.
- The clinician stays in control. Every draft is read and approved before anything is saved or sent. Nothing is filed automatically.
Impact
By the end of the preview the doctors were spending close to four fewer hours a week on documentation, almost all of it recovered from the evening, and the notes were finished the same day rather than days later. The records were also more complete than the evening write-ups they replaced. The clinic kept it in place after the trial.
“The work is the same,” the lead GP said. “I am just not taking it home.”