Pediatric Endocrinology Telemedicine Visit Note

Patient: [name, DOB, MRN]

Date/Time: [date and start time of service]

Visit Type: [New / Established] Pediatric Endocrinology – Telemedicine ([Video / Audio-only])

Provider: [clinician name and credentials]

Patient Location: [city, state where patient is physically located]

Clinician Location: [state or site]

Participants: [patient; parent/guardian with relationship; interpreter if used]

Telehealth Consent: [Verbal / Written] consent obtained per policy. (Include date/time if required by policy.)

Chief Complaint / Visit Agenda

[Reason for visit and clinical focus] (Keep to 1–2 sentences; problem-focused.)

Subjective

[Narrative HPI covering interval since last visit, interim events, symptom changes, and family's main questions or goals] (For diabetes: integrate current regimen, CGM use patterns, hypoglycemia/hyperglycemia episodes, adherence, and barriers. For thyroid/growth/adrenal/puberty: include condition-specific symptoms and medication adherence.)

Endocrine Medications: [medication name, dose, route, frequency]

Allergies: [drug, food, environmental, and adhesive allergies with reactions] (Include adhesive allergies for device users.)

Targeted ROS: [pertinent positives and negatives relevant to active endocrine problems]

Objective

Vitals: [vital signs with units and source attribution] (Example: "Weight: 32.4 kg (home scale, parent-reported)." If not obtained, briefly state why.)

Remote Data Reviewed: (For diabetes patients.)

• Source/Platform: [CGM cloud, pump portal, or device download]; Date Range: [dates reviewed]; Wear Time: [percentage if available]
• CGM Metrics: [mean glucose, GMI, time in range, time below range, time above range, CV] (Include only values available.)
• Pump/AID Summary: [relevant settings and delivery data, if applicable]
• Patterns: [clinically significant patterns observed] (If data unavailable or incomplete, document reason.)

Labs/Imaging: [test name, date, result, and brief interpretation as relevant]

Tele-Exam:

• [General appearance, alertness, work of breathing, visible skin/device sites, other focused observations] (Label each as [observed via video] or [reported by family].)

Physical exam limited by telemedicine format; no auscultation or palpation performed.

Assessment

(Numbered problem list in order of clinical priority. For each: diagnosis name, status, and brief evidence summary linking subjective and objective findings. For diabetes, make glycemic interpretation explicit using CGM metrics.)

1. [Diagnosis] — [controlled / uncontrolled / stable / improving / worsening]: [evidence summary]
2. [Diagnosis] — [status]: [evidence summary]

Plan

(For each problem, document therapeutics, diagnostics, education, and coordination. Tie changes to objective data; use before → after format for dose/setting changes.)

1. [Problem]:
   • Therapeutics: [medication or device changes with rationale; before → after]
   • Diagnostics: [labs/imaging ordered]
   • Education: [topics covered; self-management guidance]
   • Coordination: [referrals, school forms, care team updates]

Return Precautions: [condition-specific warnings] (For diabetes: severe hypoglycemia, persistent hyperglycemia with ketones or vomiting, altered mental status. For adrenal insufficiency: vomiting, inability to take oral medications, fever, injury.)

Follow-up: [interval] via [telemedicine / in-person] (Include rationale for modality choice and next data upload instructions if applicable.)

Time: (If billing by time.) Total time on [date]: [X] minutes, including [pre-visit review, counseling, care coordination, documentation].

(If information was not obtained, briefly state why rather than leaving blank. Only document findings actually performed or observed. Preserve source attribution for all patient-reported or remotely obtained data.)