Telehealth/Telephone Encounter Note

Date of Service: [Date]

Patient: [Full name]

DOB: [MM/DD/YYYY]

Encounter Modality: [synchronous audio-video telehealth via [platform] / audio-only telephone]

Reason Video Not Used: [patient inability / patient preference / technical issues] (Include only for audio-only encounters; omit entirely for video visits)

Patient Location: [City, State] (Must be explicitly confirmed by the patient during the encounter; do not assume)

Identity Verified: [name/DOB confirmation / patient portal authentication / established patient recognized with confirmatory identifier]

Consent: [verbal consent obtained / written consent on file]

Others Present: [Name(s) and role/relationship; include interpreter and language if used] (Omit this field entirely if patient alone)

Call-back Number: [Phone number]

Chief Complaint

[Primary reason for encounter] (If clinician-initiated, state the context such as results follow-up or care coordination)

Subjective

[History of present illness as narrative paragraph: onset, course, severity, associated symptoms, relevant negatives, self-care or prior treatment. Note historian if not the patient. Include telehealth-relevant context such as home monitoring data or patient-submitted photos if referenced.]

[Pertinent past medical history, medications, allergies, social history] (Include only details that directly inform today's assessment or plan; omit section if not relevant)

[Review of systems] (Include only if performed; omit entirely if not obtained)

Objective

Vitals: [Values with source noted—home cuff, connected device, patient report] (If unavailable, state reason briefly)

Remote Exam: [Findings actually observed or assessed: general appearance, speech, visible findings, functional observations as applicable to modality. Explicitly state limitations due to remote modality and what could not be assessed.] (Document only what was assessed; omit exam elements not observed; for audio-only, limit to speech patterns and inferred findings)

Data Reviewed: [Labs, imaging, prior notes, patient-submitted materials with dates] (Include only if reviewed today; omit if none)

Assessment

[Problem-oriented assessment ordered by clinical priority. For each problem: working diagnosis or clinical impression, key supporting evidence, and differential when uncertainty exists. Explicitly acknowledge telehealth limitations affecting diagnostic certainty and how they influence the plan.]

Plan

[Problem-oriented plan. For each problem addressed: diagnostics/monitoring, therapeutic interventions, referrals/coordination as applicable.]

Safety-Netting / Return Precautions: [Specific symptoms or signs that should prompt urgent evaluation; expected course and timeline; where to seek care if worsening] (Include when clinical risk is non-trivial; individualize to the patient's condition)

Shared Decision-Making: [Options discussed, patient preferences, and how agreed plan reflects those preferences] (Include only when meaningful treatment options or uncertainty exist; omit for straightforward plans)

Follow-up: [Timeframe and modality: telehealth vs in-person; contingency for earlier follow-up if indicated]