A telephone encounter note records a clinical phone call that isn’t a booked visit: who called, what you asked, the advice you gave, and where the patient goes next. Copy the free template, see an infant fever call and a chest pain triage call, and check what goes in each part.
Blank telephone encounter note template
FreeTELEPHONE ENCOUNTER NOTE Patient: [Name] Date of birth: [Date] Date and time of call: [Date, time the call came in, and time of any return call] Call type: [Incoming call, return call, after-hours line, or message follow-up] Taken by: [Name, credentials, role] CALLER Caller: [Patient, or name and relationship to the patient] Authority to discuss: [Patient on the line, parent or guardian, or contact the patient has authorized] Identity checked: [Patient's full name and date of birth, plus one more identifier] Callback number: [Number, read back to the caller] Patient location now: [Home, work, or street address, in case emergency services are needed] Language: [Language used, interpreter name or ID, or none needed] REASON FOR CALL Concern: [The main concern, in the caller's words] Onset and course: [When it started, how it has changed, what has been tried, with doses and times] Relevant history: [Conditions, medications, allergies, pregnancy, recent visits or surgery] TRIAGE Protocol used: [Protocol name from your triage protocol set, or clinician-directed] Red flags asked: [Each emergency question and the answer, present or absent] Other answers: [Positive and negative answers that set the disposition] Readings reported: [Temperature, weight, BP, glucose, or other home readings, with the device and time] ADVICE AND DISPOSITION Disposition: [Call 911 now, emergency department now, same-day visit, appointment within 24 hours or later, or home care] Change from protocol: [None, or the new disposition, the reason, and who agreed] Advice given: [Home care, any dose worked out by weight or age, and what to avoid] Warning signs: [Signs that mean call back, and signs that mean call 911, named for this problem] Prescription or result action: [Refill request, result discussed, or none; details go in their own note] Appointment: [Date, time, clinician, in person or video, or none] CONSULTATION Clinician consulted: [Name, time, and the advice or order given, or none] Orders read back: [Yes, with the order, or not applicable] Escalation: [Who was told, by what route, and when] CLOSE OF CALL Caller's understanding: [Plan repeated back by the caller, and their agreement] Call-back plan: [Who calls whom, by when, and what happens if there is no answer] Call ended: [Time, and how: caller hung up, transferred, or paramedics arrived] Signed: [Name, credentials, date and time]
Use it for
Each one follows the template. Use them to judge how much detail every part needs.
Family practice nurse line, incoming call, 12 minutes
Mother called at 08:15 about her daughter, 9 months old. Mother is listed as a parent on the chart. Identity checked with the child’s full name, date of birth, and home address. Callback number read back and confirmed. Child at home with her mother. Call in English; no interpreter needed.
“She’s been hot since yesterday morning and she’s fussy.” Fever for about 24 hours: 38.6 °C last evening, and 38.9 °C (102.0 °F) rectal at 07:30 today on a digital thermometer. Runny nose and a mild cough since yesterday; her 4-year-old brother has a cold. One dose of acetaminophen at 07:45; mother wants to check the dose and how often to give it. Born at term. No ongoing conditions, no regular medications, no known allergies. Vaccines up to date. Weighed 9.0 kg at the clinic 2 weeks ago.
Pediatric fever protocol from the clinic’s triage protocol set. Red flags, all absent: hard to wake or floppy; fast breathing, grunting, or skin pulling in between the ribs; blue or grey lips; purple or red spots that don’t fade when pressed; seizure; stiff neck; crying that can’t be soothed. Other answers: breastfeeding well, eating a little less solid food than usual. 4 wet diapers since midnight, the last 1 hour ago. No vomiting or diarrhea. Not pulling at her ears. Smiles and plays when the fever comes down. Fever under 3 days, with cold symptoms as a likely source.
Disposition: home care. Change from protocol: none. Advice: the aim is comfort, not a normal number. Acetaminophen 120 mg, about 13 mg/kg at 9.0 kg, every 4 to 6 hours as needed, no more than 5 doses in 24 hours; next dose not before 11:45. Worked out the volume with her from the strength printed on her bottle, using the syringe that came with it. Offer the breast often. Light clothing; no cool baths or rubbing alcohol. Saline drops and gentle suction for the nose before feeds. Call back for: no wet diaper in 8 hours, refusing feeds, temperature 40 °C (104 °F) or higher, fever lasting more than 3 days in total, or if she seems to be getting worse. Call 911 for a seizure, blue lips, struggling to breathe, or if she can’t be woken. Prescription or result action: none. Appointment: none booked; a same-day slot is available if needed.
None needed; disposition within the nurse protocol. Note sent to her family physician for information.
Mother repeated back the dose, the time of the next dose, and the warning signs, and agrees with home care. Call-back plan: nurse will call at 16:00 today to check on her; if no answer, a voicemail and a second try at 17:00. Overnight, mother will use the after-hours line for any warning sign. Call ended at 08:27, caller hung up.
Primary care nurse line, incoming call, 911 called during the call
Patient called at 10:40 himself. Identity checked with full name and date of birth. Callback number read back. At home with his wife; home address on file confirmed for emergency services. Call in English; no interpreter needed.
67-year-old man. “My chest went tight carrying the groceries up the stairs, and it hasn’t gone away.” Pressure in the center of the chest since 10:20, 5 out of 10, eased only a little after sitting down. Short of breath and sweaty since it started. Two shorter episodes walking uphill in the past 3 days, each easing within a few minutes of rest. History: high blood pressure, type 2 diabetes, high cholesterol; quit smoking 10 years ago. Medications: amlodipine, metformin, atorvastatin. Not on aspirin or a blood thinner. No known allergies.
Adult chest pain protocol from the clinic’s triage protocol set. Red flags: chest pressure lasting more than 5 minutes and still present, present; shortness of breath, present; sweating, present; pain spreading to the arm, jaw, or back, absent; fainting or near-fainting, absent; confusion, absent. Speaking in full sentences. Readings reported: BP 158/92 and HR 96 on his home cuff at 10:35.
Disposition: call 911 now. Change from protocol: none. Told not to drive or be driven to hospital. His wife called 911 from her mobile at 10:44 while the nurse stayed on the line with him. Aspirin questions per protocol: no allergy, no blood thinner, no recent bleeding; advised to chew one 325 mg aspirin, taken at 10:46. Advised to sit and rest, unlock the front door, keep the phone with him, and have his medication list ready for the paramedics. His wife to follow the 911 dispatcher’s instructions if he collapses. Prescription or result action: none. Appointment: follow-up after hospital assessment.
Dr. Osei, his family physician, notified by secure message at 10:47 while the nurse stayed on the line. Came to the nurse’s desk at 10:49 and agreed with 911 and aspirin. Dr. Osei will call the emergency department with his history and medication list.
Patient repeated back: sit and rest, door unlocked, wait for the paramedics. Paramedics arrived at 10:56; the nurse heard them take over and ended the call at 10:57. Call-back plan: nurse to call his wife at 14:00 for an update. Addendum 14:05: his wife reports he is being admitted for cardiac tests. Dr. Osei informed and will book a follow-up within a week of discharge.
Who was on the line, why you could discuss the patient with them, and how to reach them again.
Avoid: Writing “patient called” when a parent or partner did. The note should show who heard the advice.
The concern in the caller’s words, and the facts the protocol needs before you start.
Avoid: Writing a diagnosis in place of the symptom. “Chest went tight on the stairs” tells the next reader what was said; “angina” doesn’t.
The questions that decide where the patient goes, asked in the protocol’s order, with each answer.
Avoid: “Denies red flags.” List the ones you asked about; the negatives are what support a home care disposition.
Where the patient goes next, and what the caller was told, specific to this problem.
Avoid: “Advised to monitor.” Name the disposition and the warning signs, so anyone reading knows what the caller was told to watch for.
Who else you involved during the call, and what they said or ordered.
Avoid: A verbal order with no name or time. Write who gave it, when, and that you read it back.
A record that the caller understood the plan, and of who acts next.
Avoid: “Call back if worse” with no owner. Say who makes the next call and when, even if it’s the caller.
Parents, partners, and adult children call for patients. Record the caller’s name and relationship, and why you could discuss the patient with them.
A home care disposition rests on the red flags that were absent. Write each one you asked about, not “no red flags.”
“Advised to monitor” isn’t a disposition. Use your protocol’s terms: call 911 now, emergency department now, same-day visit, appointment, or home care.
If you send a patient in sooner or later than the protocol says, record the reason and the clinician who agreed. An unexplained change is the first thing a reviewer questions.
Record the weight you used, the dose in mg, and that the caller checked the strength on their own bottle. Liquid strengths differ between products.
Vero Scribe writes the telephone encounter note in your template from the call, with the caller’s consent, or from your dictation after you hang up. You review and edit every section, then copy it into your record or export it to Word or PDF. Vero works in 60+ languages.
The record of a clinical phone call that isn’t a booked visit: a patient or family member calling with a symptom or question, or a clinician calling them back. It records who called, the questions asked, the advice given, the disposition, and what happens if things change.
Write it during the call or right after, with the times. Record who called, their relationship to the patient, how you checked identity, and a callback number. Then the concern in the caller’s words, the red flags you asked about and the answers, the disposition, the advice and warning signs, who you consulted, and that the caller repeated the plan back.
A telehealth visit is a booked appointment by video or phone that stands in for an in-person visit, with a history, what you could examine, an assessment, and a plan. A telephone encounter is an unscheduled call, often taken by a nurse or medical assistant, and the note is built around triage: the questions, the advice, and where the patient goes next. If a call turns into a full assessment, document it as a visit.
A nurse’s record of a symptom call handled with a triage protocol. It names the protocol, lists each red-flag question with its answer, and gives the disposition the protocol reached, from call 911 now to home care. If you change that disposition, up or down, record why and who agreed. Both examples above are triage notes.
Check who the caller is first. A parent or guardian of a young child, a contact the patient has authorized, or a caller with the patient beside them on the line can usually be advised. Otherwise, follow your organization’s policy and the privacy law where you practice. You can always listen, and tell anyone to call 911 in an emergency. Record the caller’s name, relationship, and what you shared.
A call about a new symptom belongs here. Refill requests and test results have their own notes, with the medication checks or the result and its follow-up. When one call covers both, write the telephone encounter for the symptom and a separate refill or result note.
Yes. Copy it, or download it as a Word or text file. No account needed.
The SOAP note reordered: assessment and plan on top, with the history and findings below to back them.
The chart note for a refill or renewal between visits: last fill, monitoring due, safety checks, the decision, and who approved it.
Your chart note on a lab or imaging result: the value and trend, urgency, action, patient contact, and tracking.
The record of a team or family care conference: attendance, consent, each discipline’s update, decisions, and actions with owners and dates.
For bedside and clinic procedures: indication, consent, time-out, technique, findings, specimens, complications, and aftercare.
Notes from video and phone care, drafted for you to review.
Check-ins, call-backs, and next steps, documented in one place.
Nursing notes and SBAR handoffs, drafted for your review.
How to write clear nursing notes, with examples and a checklist.
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