Telehealth documentation: what to record and why it matters

Document a telehealth consultation as thoroughly as you would an in-person one — and add a short set of telehealth-specific details on top. When a remote assessment is later questioned, your notes are the record of what you knew, what you couldn’t assess, and what you advised. They are your best protection.

Here’s what to record and why it matters. This is general information, not legal advice.

Why telehealth notes carry extra weight

The baseline standard is unchanged. Records need to contain enough information to allow another practitioner to identify the patient and continue their care, and they should be accurate, clear and contemporaneous (Avant). Document at the time, or as soon as practicable afterwards.

What changes with telehealth is the risk profile. You made decisions with less information than an in-person consult would give you — no hands-on examination, limited observation, sometimes a patient you’d never met before. If an outcome is bad and the assessment is scrutinised, the question becomes: was telehealth reasonable here, and did you act appropriately given its limits? A good note answers that. A thin one leaves it open.

The note isn’t just a clinical aide-memoire — in a remote consult it’s the evidence of your reasoning. If you can’t examine the patient, the least you can do is record clearly what you assessed, what you couldn’t, and how that shaped the plan.

The telehealth-specific details to record

Alongside your usual history, assessment and plan, the medical defence organisations and the RACGP point to a consistent set of telehealth extras. MDA National’s toolkit lists the elements to capture in the record (MDA National); the RACGP adds specifics around consent and who is present (RACGP); and Avant’s telehealth checklist reinforces recording the modality and rationale (Avant).

What to record	Why it matters
That the consult was by telehealth, and whether video or phone	Establishes the modality and its inherent limits
Why telehealth was appropriate (rationale)	Shows you considered clinical suitability
Patient identity confirmed, and location	Verification and safety (escalation, jurisdiction)
Who else was present, and consent to their presence	Privacy and consent trail
Consent to the telehealth format	Meets the documented-consent expectation
Any technical problems affecting the consult	Flags where assessment quality may have been limited
Limitations of the remote assessment	Records what you could not evaluate
Assessment, plan, prescribing and referrals	Core clinical record
Safety-netting advice given	Shows you set out what to watch for and when to seek help
Follow-up arrangements, including any in-person review	Continuity of care

You don’t need a paragraph on each. A few well-chosen lines covering these points is enough, and much of it can live in a note template.

Record the limits of the assessment

This is the element most often left out, and the most valuable. If you couldn’t examine an abdomen, palpate a lump, or take vital signs, say so — and say how you compensated (patient self-examination on camera, asking about red-flag symptoms, arranging tests). Noting the limitation isn’t an admission of weakness; it’s evidence that you understood the constraints of the medium and worked within them. If the remote assessment was insufficient and you converted to in-person, record that decision too — see when telehealth is not appropriate.

Safety-netting belongs in the note

Safety-netting and documentation go together. Tell the patient what to watch for, what to do if things worsen, and when to seek in-person or emergency care — then write down that you did. In a remote consult, where you can’t lay eyes on the patient again unless they come back, explicit safety-netting is both good care and good protection. Document the specific advice, not just “safety-netted”.

Consent is part of the record

Documenting consent is a documentation task as much as a consent task. Record that the patient consented to telehealth after its limitations were explained, and that you took the usual consent for what you did clinically. The two fit in a line. For the consent side in detail, see informed consent for telehealth; for the broader regulatory picture, see the Ahpra telehealth guidelines.

Recording the call is not note-keeping

A recurring point of confusion: video recording is not a substitute for a written record, and it introduces consent and storage obligations of its own. Most consults should not be recorded at all. Keeping a good contemporaneous note — while using a platform that doesn’t record by default — is cleaner, safer and easier to defend. It also keeps you the accountable author of the record. That obligation to ensure the record’s accuracy stays with you even when software or AI tools help generate it (Avant).

Keep the record in your clinical system

Telehealth notes should live where the rest of the patient’s record lives — your practice-management or clinical software — not stranded in a video tool. That keeps the history complete, makes access and correction requests manageable, and means your documentation isn’t hostage to a third-party platform. It’s one reason to choose telehealth software that stays out of your records: MedCall, for example, does the video only and is Australian-hosted and never records, so your notes and billing remain in the systems you already use.

A workable habit

Build a short telehealth note template into your clinical software covering modality, rationale, identity and location, who was present, consent, any tech issues, assessment limitations, plan, safety-netting and follow-up. Fill it out as you go — narrate to the patient while you type (“I’m just noting that down”) so the silence doesn’t feel long. Contemporaneous beats reconstructed every time.

The bottom line

Telehealth documentation is ordinary good record-keeping plus a handful of medium-specific details: that it was telehealth, why it was appropriate, what you couldn’t assess, who was present, that consent was obtained, and what you advised. Record it clearly, at the time, in your clinical system — and don’t rely on recordings in place of notes. For the standards, see Avant’s medical records essentials and the RACGP’s principles for conducting telehealth consultations.