Dictate after the call. Get the note.
After a video or phone visit, dictate what you found. Vero Scribe writes it in your telehealth template for you to review and edit, then copy into your EHR or export to PDF or Word.
Telehealth Visit Note Template
A telehealth visit note records a video or phone visit: how it was done, what you could and couldn’t assess, and when the patient needs to be seen in person. Copy the free template, see a video and a phone example, and check what goes in each part.
- Free, no account needed
- Word and text downloads
- Two filled examples
Blank telehealth visit note template
FreeTELEHEALTH VISIT NOTE Patient: [Name] Date of birth: [Date] Date and time: [Date, start and end time] Clinician: [Name, credentials, and where you were during the visit] VIRTUAL VISIT DETAILS Modality: [Video or phone, and the platform] Patient location: [Where the patient is, such as home or work, and a callback number] Identity confirmed: [How, such as full name and date of birth, or photo ID shown on video] Others present: [Anyone else on the call, such as a family member or interpreter, with the patient's agreement, or none] Consent: [Verbal consent to a virtual visit, after discussing its limits and privacy] Technology: [Connection quality, interruptions, and any switch from video to phone] HISTORY Reason for visit: [In the patient's words] History of present illness: [Onset, course, symptoms, and what has been tried] Red flags: [Warning symptoms asked about, present or absent] Medications and allergies: [Current medications and recent changes; allergies with reactions] Relevant history: [Past medical, family, and social history that bears on the problem] REMOTE EXAMINATION Observed on video: [Appearance, breathing, speech, and the area shown, with the lighting and image quality] Heard on the call: [Voice, breathing, cough, or confusion, for phone visits] Patient-reported measurements: [Home readings with the device and time, such as BP, HR, temperature, weight, or glucose] Photos reviewed: [Images the patient sent, and when they were taken] Exam limitations: [What could not be assessed remotely] ASSESSMENT Impression: [Diagnosis or working impression, with the findings that support it] Suitable for virtual care: [Yes, or why an in-person exam is needed] PLAN Treatment: [Medications with dose, route, and frequency, and the pharmacy the prescription was sent to] Tests: [Labs or imaging ordered, and where the patient will go] In-person visit: [Whether one is needed, how soon, and why] Follow-up: [When, and whether by video, phone, or in person] SAFETY NET Warning signs: [Symptoms that need a same-day call or visit] Emergency: [When to call 911 or go to the nearest emergency department] Understanding: [Plan repeated back by the patient, and how they will reach the clinic] Signed: [Clinician name, credentials, date and time]
Use it for
- Video visits
- Phone follow-ups
- Medication reviews
- Results discussions
- After-hours virtual care
Two filled examples. Every part, filled in.
Each one follows the template. Use them to judge how much detail every part needs.
Telehealth visit note: rash by video
Primary care, video visit
Virtual visit details
Video visit on the clinic’s secure platform. Patient at home, alone; callback number confirmed. Identity confirmed with full name and date of birth. Verbal consent to a virtual visit after discussing its limits. Good connection; lighting adequate once she moved near a window.
History
58-year-old woman with burning pain on the right side of her chest and back for 3 days, and a rash in the same area since yesterday. Pain 6 out of 10, worse when clothing touches the skin. Red flags: no fever, headache, confusion, or weakness; no rash on the face or near the eyes; no eye pain or change in vision. Had chickenpox as a child; no zoster vaccine. No conditions or medications that weaken the immune system. Medications: none. Allergies: none known.
Remote examination
Observed on video: comfortable, speaking normally. Clusters of small blisters on a red base in a band from the right mid-back around to below the right breast, stopping at the midline. No lesions on the face, scalp, or tip of the nose. Photos sent this morning show the same. Patient-reported temperature 37.2 °C (99.0 °F) on a home digital thermometer. Limitations: could not touch the rash, check the rest of the skin in detail, or examine the eyes.
Assessment
Herpes zoster in a right thoracic dermatome, within 72 hours of rash onset: typical appearance on video and in the photos, with pain in the same band before the rash. No signs of eye involvement or spread beyond one dermatome. Suitable for virtual care.
Plan
Valacyclovir 1 g by mouth three times daily for 7 days, sent to her pharmacy; no kidney disease. Acetaminophen or ibuprofen for pain; loose clothing; keep the rash covered. Until all the blisters have crusted, avoid contact with pregnant people who haven’t had chickenpox, newborns, and anyone with a weakened immune system. In-person visit not needed now. Video follow-up in 1 week. Discuss the recombinant zoster vaccine once the rash has healed.
Safety net
Same-day call for a rash spreading beyond this area, fever, or pain not controlled. Same-day in-person assessment for any rash on the face or near the eye, eye pain or redness, or a change in vision. Call 911 for confusion, a severe headache with a stiff neck, or weakness. She repeated the plan back and has the clinic’s after-hours number.
Telehealth visit note: blood pressure medication review by phone
Primary care, phone follow-up
Virtual visit details
Phone visit; the patient has no device for video. Patient at home; callback number confirmed. Identity confirmed with full name, date of birth, and address. His wife joined on speakerphone, with his agreement. Verbal consent to a phone visit after discussing its limits. Clear line throughout.
History
70-year-old man, scheduled review 8 weeks after starting ramipril 5 mg daily for hypertension. Takes it every morning. Dry, tickly cough for 5 weeks, worse at night. Red flags: no fever, sputum, coughing up blood, wheeze, breathlessness, chest pain, or ankle swelling; no swelling of the lips, tongue, or face. Nonsmoker; no recent cold. Other medications: none. Allergies: none known.
Remote examination
Phone only, no visual exam. Heard on the call: speaking in full sentences, voice normal, dry cough twice during the call, no audible wheeze. Patient-reported measurements: home BP on a validated upper-arm cuff, average of 14 readings over 7 days, 128/78, HR 70. Limitations: no chest exam, throat exam, or check for ankle swelling.
Assessment
Hypertension, at target on home readings. Dry cough most likely caused by ramipril: it started within weeks of the drug, with no signs of infection, asthma, or heart failure by history. A chest exam is needed if the cough doesn’t settle after stopping ramipril. Suitable for virtual care today.
Plan
Stop ramipril. Start losartan 50 mg daily, sent to his pharmacy. Creatinine and potassium in 1 to 2 weeks. Home readings twice daily for 1 week before the next call. Phone follow-up in 4 weeks. In-person visit with a chest exam if the cough is not clearly better by then; it can take a few weeks to settle.
Safety net
Call 911 for swelling of the lips, tongue, face, or throat, or trouble breathing. Same-day call for fever, coughing up blood, breathlessness, chest pain, or dizziness on standing. He and his wife repeated the plan back.
What goes in each part.
Virtual visit details
How the visit happened. These lines frame the rest of the note, and many regulators and payers expect them.
- Video or phone, and the platform
- The patient’s location and a callback number
- How you confirmed identity
- Verbal consent, after explaining the limits of a virtual visit
- Others on the call, and any technical problems
Avoid: Assuming the patient is at home instead of asking where they are and how to call them back.
History
The same history you would take in person, with more weight on it because the exam is limited.
- The reason for the visit, in the patient’s words
- Onset, course, and what has been tried
- Red-flag questions, asked directly
- Medications and allergies, confirmed
Avoid: Skipping the red-flag questions that an in-person exam would normally answer.
Remote examination
What you observed, and what the patient measured, kept apart and labeled.
- What you saw on video: appearance, breathing, speech, the area shown
- What you heard on a phone call
- Home readings labeled as patient-reported, with the device
- Photos reviewed, and when they were taken
- What you could not assess
Avoid: Writing findings you couldn’t check remotely, such as “lungs clear” or “abdomen soft.”
Assessment
Your impression, and whether a remote assessment was enough to make it safely.
- The diagnosis or working impression
- The findings that support it
- What still needs an in-person exam to rule out
- Whether virtual care was suitable
Avoid: Implying more certainty than a remote assessment allows.
Plan
What happens next, including whether and when the patient needs to be seen in person.
- Medications with dose, and the pharmacy the prescription went to
- Tests, and where the patient will go
- An in-person visit, with a time frame and a reason
- The next contact, and whether it is by video, phone, or in person
Avoid: Writing “see in person if needed” with no time frame or trigger.
Safety net
The warning signs, and exactly what to do about each, because you won’t see how the patient looks when they leave.
- Symptoms that need a same-day call or visit
- When to call 911 or go to the emergency department
- How to reach the clinic, including after hours
- Confirmation that the patient understood
Avoid: Generic advice like “call if worse” instead of the signs that matter for this problem.
Common mistakes, and how to avoid them.
Not confirming location every time
Patients join from work, the car, or another city. Confirm where they are at each visit: it matters in an emergency and, depending on your regulator or payer, for whether you can provide the visit.
Not recording technical problems
A frozen picture or poor lighting limits what you could see. Note it, so the next reader knows how much weight the observations carry.
Treating home readings as clinic measurements
Label patient-reported values as such, with the device, the time, and the number of readings.
Staying virtual too long
When the problem needs a hands-on exam, or isn’t improving as expected, book an in-person visit and record why.
Missing consent
Record verbal consent to a virtual visit, and the limits you explained, at every visit. One line covers it.
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Frequently asked questions.
What should a telehealth visit note include?
The modality, the patient’s location, how you confirmed identity, and consent to a virtual visit. Then the history, what you could observe, patient-reported readings, the limits of the exam, and a plan that says whether the patient needs to be seen in person.
Do I need to document consent for a telehealth visit?
Most regulators and organizations expect it. Note that the patient agreed to a virtual visit after you explained its limits and how their privacy is protected, and check your regulator’s or payer’s requirements for anything more.
Why record the patient’s location?
So you can send emergency help to the right place, and because where the patient is can affect whether you can provide the visit and how it is billed. Confirm it at every visit.
How do you document a physical exam on a video visit?
Record what you observed, such as appearance, breathing, and the area the patient showed you, and label home readings as patient-reported. Then note what you could not assess remotely.
Is a phone visit documented differently from a video visit?
The parts are the same, but there is no visual exam. Note what you could hear, such as speech, breathing, and cough, and rely on patient-reported readings, with their limits stated.
Is this telehealth visit note template free?
Yes. Copy it, or download it as a Word or text file. No account needed.
More family medicine and primary care templates, and guides.
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Common ICD-10 codes
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Your template. Filled in from the visit.
Vero writes your notes and letters in the templates you choose, so you review instead of type.
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