Telemedicine
Telehealth visit note template
A remote-consultation note that records the elements payers and regulators require: consent, modality, both parties' locations, and what could not be examined.
Best used for
- Video consultations
- Telephone reviews
- Remote follow-ups
- Cross-border teleconsulting
Template structure
Each section shows what to document and a worked clinical example.
Modality used, start and end time, who was present, the patient's location, the clinician's location, and confirmation of verbal consent to a remote consultation.
Example
Video consultation, 14 minutes. Patient at home, clinician at clinic. Patient alone and in a private room. Verbal consent obtained for remote assessment and for AI-assisted documentation.
History as in any consultation, plus anything the patient can self-measure such as home blood pressure, glucose or temperature readings.
Example
Follow-up of hypertension. No headache, chest pain or breathlessness. Home readings averaging 138/84 over the past week. Taking amlodipine 5 mg daily without ankle swelling.
What you could genuinely observe remotely, then state plainly what could not be examined and how that constrains the assessment.
Example
Appears well, speaking in full sentences, no visible distress or pallor. Unable to auscultate the chest or palpate the abdomen; cardiovascular examination not possible remotely.
Impression acknowledging remote limitations, the plan, and the explicit threshold at which the patient must be seen in person or attend emergency care.
Example
Hypertension adequately controlled on current therapy. Continue amlodipine 5 mg. Repeat home readings for two weeks. Attend in person if readings exceed 160/100, or attend emergency care for chest pain, breathlessness or neurological symptoms. Review in one month.
Documentation tips
- Record consent to the remote modality — it is the most commonly missing element in telehealth audits.
- Name the examination components that were not possible; this protects both patient and clinician.
- Always document an in-person escalation trigger.
Frequently asked questions
- What must a telehealth note include that an in-person note does not?
- Consent to remote care, the modality used, both parties' locations, the limitations of remote examination, and an in-person escalation threshold.
- Why record the patient's location?
- Licensing, emergency escalation and reimbursement rules often depend on where the patient physically is during the consultation.
- Can ScribeMDPro document a telephone consultation?
- Yes, provided the patient consents. Audio is processed for transcription and is not retained after the note is drafted.
- Does this template satisfy payer requirements?
- It covers the elements payers most commonly require, but always check the specific rules of your jurisdiction and payer.
More templates
Let ScribeMDPro draft your telemedicine notes.
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