Pediatric Neurology Telemedicine Visit Note

Date: [Encounter date]

Patient: [Auto-populated name, DOB, MRN]

Provider: [Clinician name and credentials]

Visit type: [new / follow-up]

Telemedicine modality: [audio-video / audio-only]

Patient location: [City, State]

Provider location: [Location]

Participants present with patient: [Parent/guardian name and relationship; others on call; interpreter if used]

Telemedicine consent: [verbal / written, date if required]

Telemedicine limitations: [Specific factors affecting this encounter] (Describe video quality, patient cooperation, space constraints, and which exam elements were not assessable.)

Subjective

Chief Complaint: [Brief phrase]

[History of Present Illness narrative] (Include onset, time course, frequency, triggers, functional impact, prior evaluations, and treatment response. For follow-ups, include interval history with symptom trend, new events, adherence, and barriers. Integrate condition-specific details such as seizure semiology, headache characteristics, movement phenomenology, or developmental milestones within this narrative.)

Medications: [Current medications with doses; recent changes]

Allergies: [Allergies with reaction types]

Relevant History: [Pertinent past medical, family, and social history] (Include only if it informs today's assessment.)

Review of Systems: [Pertinent positives/negatives] (Include only if specific systems review changes management; otherwise omit.)

Objective

General appearance/behavior: [Alertness, interaction, cooperation, behavior pertinent to neurologic assessment]

Vitals: [Values if available] ([home measurement / recent clinic visit / not obtained])

Tele-neurologic examination:

• Mental status: [Observed findings; elements not assessable and why]
• Cranial nerves: [Observed findings by visualization; elements not assessable due to telemedicine]
• Motor: [Observed bulk, movement, antigravity strength, asymmetries; elements not assessable and why]
• Coordination: [Observed tasks and results; if not performed, state reason]
• Gait/station: [Observed findings with safety precautions noted; if not assessed, state reason]

(Do not document normal findings for elements that could not be reasonably assessed remotely.)

Data Review

[Studies reviewed with type, date, report vs. independent review, and key findings] (Include EEG, neuroimaging, labs, genetic testing, developmental/neuropsych testing, and caregiver-provided videos as applicable. Note any records not available that affect decision-making.)

Assessment

(Problem-oriented list in order of clinical importance. For each problem: working diagnosis or symptom-based assessment, status, and key supporting evidence. State when exam limitations affect diagnostic certainty or when in-person evaluation is needed.)

[Problem 1]: [Working diagnosis or symptom-based assessment]

Status: [improving / stable / worsening / controlled / uncontrolled]. [Key supporting evidence from history, tele-exam, and data; impact of telemedicine limitations on certainty if relevant]

[Problem 2]

(Include only if additional problems were addressed.)

Status: [improving / stable / worsening / controlled / uncontrolled]. [Supporting evidence and limitations as above]

Plan

(Organize by problem. State explicitly when information is not available or not assessed.)

[Problem 1]

[Diagnostics/monitoring ordered; medication changes with dose and titration; non-pharmacologic interventions; counseling provided]

Contingency: [Specific thresholds for urgent care vs. ED; actions if symptoms worsen; backup communication plan]

[Problem 2]

(Include only if additional problems were addressed.)

[Diagnostics, medications, interventions, and counseling as above]

Contingency: [As above]

Follow-up: [Timeframe] [telemedicine / in-person] (Note who should attend and any pre-visit data needed.)