TELEHEALTH 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]