Pediatrics Telemedicine Visit Note

Date/Time: [Encounter date and time]

Patient Location: [City, State where child is located during visit]

Clinician Location: [State and care setting]

Modality: [video / audio-only] (If audio-only, include brief reason.)

Consent: [Telemedicine consent confirmed with: guardian name, relationship]

Participants: [Names/roles of those present; whether any portion conducted privately with adolescent: yes/no]

Historian: [Primary historian(s) and reliability] (Note any limitations such as language barriers, connectivity issues, or caregiver uncertainty.)

Subjective

[Chief complaint in patient's/parent's own words]

[History of Present Illness] (Narrative addressing onset, duration, severity, associated symptoms, functional status including feeding/urine output/activity, exposures, home interventions tried and response, and any prior evaluations. For chronic condition follow-ups, include interval control and adherence.)

Background

• [Current medications with doses and adherence] (Include only items relevant to today's visit.)
• [Allergies with reaction type]
• [Pertinent past medical history] (Omit unrelated history. Include birth/neonatal history for infants or respiratory concerns.)

Remote Examination

Home vitals: [Parent-reported measurements if available: temperature, weight, oxygen saturation] (If unavailable, state reason.)

Video observations: [Pertinent findings by system: general appearance/alertness/consolability, work of breathing, skin color/rash, hydration cues, HEENT if visualized, neurologic/behavioral observations]

Caregiver-assisted maneuvers: [Maneuvers performed and findings] (Acknowledge reliability limitations.)

Limitations: [Elements not assessable remotely] (E.g., auscultation, capillary refill, otoscopy, rash texture. Tailor to case and note impact on diagnostic confidence.)

Assessment

• [Problem 1]: [Working diagnosis or symptom-based impression]
  • [Key supporting history and remote exam findings]
  • [Pertinent differential diagnoses if uncertainty is meaningful]
  • [Telemedicine limitations affecting diagnostic confidence] (If applicable.)
• [Problem 2]: [Working diagnosis] (Additional problems as needed.)
  • [Supporting findings and differential as applicable]

Plan

• [Problem 1]:
  • [Therapeutic interventions with pediatric weight-based dosing]
  • [Diagnostics ordered and where to obtain]
  • [Patient/caregiver education provided]
  • [Follow-up timing and modality]
• [Problem 2]:
  • [Interventions, diagnostics, education, follow-up as applicable]

Safety-Net Instructions:

• Call clinic if: [Early warning signs appropriate to presentation]
• Seek same-day in-person/urgent care for: [Worsening or new concerning symptoms]
• Go to ED or call 911 for: [Red-flag symptoms: respiratory distress signs, dehydration markers, neurologic changes, toxic appearance as relevant to presentation]