Pediatric Pulmonology Telehealth Visit Note

Date of Service: [Date of service] Patient: [Patient full name] DOB: [DOB] Provider: [Provider name, credentials]

Visit Type: [Video / Audio-only] Patient Location: [City, State] Provider Location: [City, State]

[Identity verification method] [Consent obtained from and relationship] [Participants present] [Interpreter and language, if used] [Emergency callback number verified] [Plan if disconnected] [Reason for audio-only, if applicable] (Compose as 1–3 concise narrative sentences.)

Chief Complaint

[Reason for visit in one line] ["Brief patient/caregiver quote clarifying severity, if applicable"]

History of Present Illness

[Historian and relationship] [Interval since last pediatric pulmonology visit] [Respiratory symptom pattern and control: cough character/timing, wheeze, dyspnea, nocturnal symptoms] [Caregiver-reported work of breathing observations] [Home vitals with source, timestamp, and device type; state explicitly if unavailable] [Exacerbations or acute care since last visit: ED visits, hospitalizations, steroid or antibiotic courses] [Therapy and device adherence: controllers, rescue medications, airway clearance, PAP or oxygen if applicable] [Environmental exposures or triggers] [Family goals for this visit] [Pertinent past medical history, medications, allergies, and relevant family or social history as indicated] (Write as a concise narrative paragraph. Explicitly state when key data are unavailable rather than omitting.)

Objective

(All objective data must be source-labeled: observed by clinician via video, caregiver-reported, home device measurement, connected device/remote monitoring, or outside record with source and date.)

• Home Vitals: [SpO2, HR, RR, temperature with source, device type, and timestamp as available] (If none available, state "Not available.")
• Exam (Telehealth—Observed): [General appearance] [Work of breathing: retractions, nasal flaring, respiratory rate estimate] [Audible respiratory sounds: wheeze, stridor, cough character] [Color in visible areas] [Interaction and alertness] [Device technique observed, if applicable] [Limitations of remote exam] (Document only findings directly observed via video. For audio-only visits, explicitly state exam limitations and describe assessable findings: voice quality, dyspnea during speech, audible cough.)
• Data Reviewed: [Pertinent diagnostics reviewed today with dates, source, and brief clinical interpretation: PFTs, imaging, sleep studies, labs, device downloads, outside records] (Distinguish reviewed data from items ordered.)

Assessment and Plan

(Organize by problem, ordered by acuity. For each problem provide a brief assessment statement with supporting data, then the plan.)

[Problem 1]: [Diagnosis or clinical impression]

[Assessment: control/severity status; salient supporting data] [Telehealth limitations affecting decision-making, if any]

• Diagnostics/Medications: [Tests or monitoring ordered; medication starts or adjustments with drug, dose, route, frequency, device, and rationale]
• Devices/Adherence/Environment: [Interventions for technique, equipment, adherence supports; trigger mitigation steps]
• Education: [Topics covered; understanding documented]
• Safety-Net: [Escalation thresholds including symptoms and SpO2 values warranting urgent evaluation; when to call EMS]
• Follow-Up: [Timing and modality; clinical rationale for in-person if recommended; care coordination performed]

[Problem 2]: [Diagnosis or clinical impression]

(Include only if additional problems were addressed. Follow same structure as above.)

(Omit sections not relevant to the encounter. Use "Not assessed" or "Not available" only when omission could be misinterpreted as a negative finding or when safety-critical. Never infer unmeasured vitals or unperformed exam components.)