Genetic Counseling Telehealth Visit Note

Date of Service: [Date of service and start time]

Patient: [Full name] | [DOB] | [MRN]

Encounter Type: [Initial / Follow-up / Results Disclosure / Post-test Follow-up]

Referring Clinician/Service: [Referring clinician or service name]

Primary Care Provider: [PCP name]

Telehealth Attestation

• Modality and Platform: [synchronous video / audio-only telephone] via [Platform name]
• Patient Location: [City, State]
• Provider Location: [City, State]
• Identity Verification: [Method used]
• Telehealth Consent: [obtained / not obtained] (If not obtained, document reason.)
• Participants Present with Patient: [Names and relationships with consent for presence noted / Patient alone]
• Privacy Confirmed: [Patient confirms private setting comfortable for discussing genetic information / Not confirmed]
• Recording Status: [No recording by clinic; patient advised not to record / Other]
• Technology Limitations: [None / Description of issues, clinical impact, and mitigations]
• Audio-only Reason: [Patient preference / Bandwidth issues / Failed video connection / N/A]
• Interpreter: [Not used / Used: Language, Interpreter ID, Modality]
• Emergency Readiness: Callback number: [Number]; Address for emergency services: [Address]; Disconnection plan: [Plan]

Reason for Referral

[Primary indication for the visit and patient-stated goals or questions] (One to two sentences. Use direct quotes for important preferences or values. If referral reason is unclear, state explicitly.)

History of Present Illness

[Narrative beginning with referral context, organized chronologically: pertinent personal history relevant to indication, prior genetic evaluations and testing with results if known; for results disclosure visits, restate testing context] (Use phrasing such as "by patient report" for items not directly assessed via telehealth. Document attempts to obtain missing records and information still needed.)

Pertinent Medical History

(Include only categories relevant to the indication. State "Not reviewed today" for categories not addressed rather than omitting.)

• Past Medical History: [Relevant history / Not reviewed today]
• Past Surgical History: [Relevant surgeries with dates / Not reviewed today]
• Medications: [Current medications / Not reviewed today]
• Allergies: [Allergens and reactions / Not reviewed today]
• Relevant Screening/Surveillance: [Colonoscopy, mammogram/MRI dates and results / Not reviewed today]
• Developmental History: [Milestones, services, evaluations / Not reviewed today / N/A] (For pediatric cases.)
• Pregnancy History: [Gravida/para, gestational age, exposures, ultrasound findings / Not reviewed today / N/A] (For prenatal cases.)

Family History

[Three-generation family history summary] (For each relevant relative: relationship, current age or age at death, key diagnoses with ages at diagnosis; clarify maternal vs. paternal lineage. Use respectful sex and gender documentation, clarifying which attributes are used for inheritance assessment when relevant.)

• Maternal Lineage: [Summary of relevant history]
• Paternal Lineage: [Summary of relevant history]
• Ancestry/Ethnicity: [Details relevant to risk assessment or test selection]
• Consanguinity: [Denied / Present / Unknown / Not assessed]
• Limitations: [Adoption / Donor conception / Estrangement / Unknown history / None]
• Reliability: [Patient-reported, not confirmed with records / Specific diagnoses confirmed by records]
• Pedigree: [Uploaded to Media tab, dated / Not available]

Records Reviewed

• [External records reviewed with dates and sources]
• [Prior genetic test reports: gene(s), variant nomenclature, classification, laboratory, report date]
• [Relevant labs, imaging, or pathology]

(If no outside records available, state: "No outside records available for review today.")

Observations

(Include only if clinically relevant. Omit entirely for routine counseling-only visits.)

• Observable via video: [General appearance and affect]
• Not assessable: [Vitals, detailed examination, etc.]

(For audio-only encounters: "No visual assessment possible.")

Genetic Counseling Discussion

Patient Goals: [Patient questions and goals for the session; agenda covered]

Education Provided: [Condition overview, inheritance pattern, penetrance and expressivity, differential diagnosis framing, how personal and family history inform risk assessment] (Tailor to indication.)

Testing Options Discussed: [Options presented and rationale; benefits and limitations; residual risk after negative testing; possibility of VUS and potential reclassification; relevant technical limitations]

• Informed Consent Elements: [Result categories reviewed; secondary/incidental findings discussion and patient preference; implications for management and family; privacy and genetic discrimination considerations; data sharing preferences; logistics including sample type, collection, turnaround time, insurance plan]
• Psychosocial: [Emotional response, coping, perceived risk, decisional conflict; health literacy techniques used and patient's demonstrated understanding]

Decision: [Patient elected to proceed with (test name) / Patient declined or defers testing: (reason documented without judgment)]

Assessment

[Clinical summary and working risk assessment: suspected condition(s) with supporting reasoning; salient positives and negatives from personal and family history; whether criteria for testing are met] (For results disclosure: include clinical interpretation with limitations and residual risk. Label inferences explicitly. Include uncertainty statements where evidence is incomplete.)

Plan

• Testing: [Test ordered, laboratory, specimen type, collection coordination, prior authorization plan, consent method, sample collection instructions if home kit, recontact policy for variant reclassification]
• Management Recommendations: [Risk-appropriate screening and surveillance tied to history, family history risk tier, and current test status; referrals for physician oversight if needed]
• Family Implications: [Cascade testing recommendations with rationale; resources provided; encouragement for patient-mediated sharing]
• Follow-up: [How results will be returned; expected turnaround time; return precautions; follow-up appointment plan]

Counseling Time: [Total minutes in counseling and care coordination]

Genetic Counselor: [Name, credentials] | [State licensure] | [Contact information]

Communication: [Note sent to referring provider and/or PCP: recipients and method]