Telemedicine Visit Note

Date/Time: [Encounter date and time] (Include time zone if cross-jurisdictional)

Patient: [Full name]; [Date of birth]

Clinician: [Full name, credentials]

Encounter Type: [new patient / established patient]

Telemedicine Encounter Details

Modality: [synchronous audio-video / synchronous audio-only / store-and-forward] (Document the actual modality used. Note any mid-encounter changes and their clinical impact.)

Patient Location: [City, State] (Include full street address only when needed for emergency planning.)

Clinician Location: [Facility name and/or State]

Identity Verification: [Method used to verify identity]

Participants: [Names/roles at patient site and clinician site] (Include caregivers, staff, interpreters, observers as applicable.)

Consent: [written on file / verbal obtained today] (Document that the patient agreed to telemedicine and understands it as an alternative to in-person care.)

Limitations: [Telemedicine-related limitations specific to this case] (Briefly state what could not be assessed due to the modality; avoid boilerplate-only language.)

Contingency Plan: [Verified callback number]; [Instructions if urgent symptoms arise or if connection fails]

(If modality, patient location, or consent cannot be confirmed, insert: "Note cannot be finalized without confirmed [modality / patient location / consent].")

Subjective

Chief Complaint: [One-line, patient-centered statement] (Use direct quotation if it clarifies nuance.)

History of Present Illness: [Narrative HPI covering onset, course, severity, associated symptoms, pertinent negatives, prior evaluations, and patient goals] (Include telemedicine-specific context when relevant. If key information is unknown, document why.)

Relevant History: [Pertinent PMH, current medications, allergies] (Include when prescribing, changing therapy, or making new diagnoses. If medication reconciliation could not be completed, state why.)

Objective

Vitals: [Available vitals with source] (Identify source: patient report, home device, or facility staff. If clinically important vitals are unavailable, document how this affected decisions.)

Telemedicine Exam: [Findings by system as applicable to chief complaint] (Document only what was actually assessed via the modality used. Do not import in-person exam language or describe findings as normal unless actually assessed. Use "limited" or "unable to assess" explicitly for areas that could not be evaluated. For patient-performed maneuvers, note compliance and quality.)

Data Reviewed: [Labs, imaging, external records, and/or patient-submitted media as applicable] (For media, note type, body site, quality limitations, and how it influenced clinical judgment.)

Assessment

[Problem list organized by acuity with working diagnosis, differential if applicable, and trajectory for each] (When exam limitations create diagnostic uncertainty, state this explicitly. Example: "Cannot exclude cellulitis versus DVT due to limited exam; in-person evaluation recommended if...")

Plan

[Management organized by problem, including diagnostics/monitoring, therapeutics with dose/route/frequency/duration/indication, referrals with rationale, and patient education/shared decision-making summary as applicable]

Follow-up: [Specific timeframe] via [telemedicine / in-person]. [Symptom-based return precautions tailored to the complaint] (Avoid vague "return if worse.")

Criteria for In-Person Evaluation: [Complaint-specific symptoms or thresholds that should prompt in-person care; emergency red flags with explicit directive to seek emergency services]

Electronic Signature: [Clinician name, credentials] — [Date and time]