Telehealth Visit Note (Family Medicine)

Date of Service: [Date of service]

Patient: [Patient name and identifiers]

Provider: [Rendering clinician name and credentials]

Visit Type: [Telehealth – Video / Telehealth – Audio-Only]

Telehealth Encounter Details

Patient Location: [Physical location including state; setting (home / facility / other); callback number]

Consent: [Informed consent documentation] (State consent obtained and type [verbal / written]; note that limitations were reviewed.)

Limitations: [Exam and data limitations related to telehealth modality] (Brief, visit-specific. If video-to-audio transition or technical issues occurred, note here with timing and mitigation.)

Subjective

Chief Complaint: [One-line chief complaint] (May quote patient.)

HPI: [Chronological narrative] (Include onset, duration, severity, trajectory, associated symptoms and pertinent negatives, exacerbating/relieving factors, self-care and response, relevant context. Note telehealth-relevant observations such as limited visualization or lack of home devices when they affect assessment.)

Relevant History: [Pertinent medications with adherence, allergies, targeted PMH/FH/SH] (Include only if it informs today's assessment. If key history is unknown, state why and how it will be obtained.)

Objective

Vitals: [Vital signs with source] (List only vitals actually obtained; label source such as patient-reported via home cuff, device-reported, or in-clinic.)

Virtual Exam: [Pertinent findings by system] (Document only observations actually made during the encounter. Organize by system using brief descriptive phrases. For patient-guided maneuvers, note findings are patient-reported under guidance. Omit systems not assessed.)

Data: [Relevant labs, imaging, outside records, or patient-submitted photos reviewed] (Only include if items were reviewed.)

Assessment & Plan

(Organize by problem, highest acuity first. For each problem, state whether new vs. established and stable vs. worsening. Include differential when uncertainty exists and acknowledge when telehealth limitations affect diagnostic certainty.)

[Problem 1]: [Working diagnosis / assessment]

[Plan narrative including diagnostics ordered with location, medications with indication and safety counseling, non-pharmacologic recommendations, referrals with urgency, patient education, and follow-up interval and modality]

Return Precautions: [Specific symptoms warranting urgent evaluation; where to seek care; timeframe] (Include for conditions with risk of deterioration or diagnostic uncertainty.)

[Problem 2]: [Working diagnosis / assessment]

[Plan narrative]

Return Precautions: [Urgent symptoms and actions] (Include if applicable.)

(Repeat additional problem sections as needed.)

Clinician Signature: [Provider name, credentials]

Timestamp: [Date and time of signature]