Doctor Telehealth Visit Documentation
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Create a telehealth visit documentation framework for [visit type].

Telehealth details (placeholders):
- Visit type: [established patient follow-up/new concern/medication management]
- Platform: [compliant telehealth platform]
- Patient location: [state]
- Provider location: [state]
- Technical quality: [good/fair/poor]
- Consent: [verbal telehealth consent obtained]

TELEHEALTH VISIT DOCUMENTATION

TELEHEALTH ATTESTATION
- Visit conducted via [audio-video/audio only if applicable]
- Patient location confirmed: [state]
- Provider location: [state]
- Telehealth consent: [obtained verbally at start of visit]
- Patient identity confirmed: [name/DOB]
- Technical quality adequate for clinical assessment: [yes/no]

CHIEF COMPLAINT
[Patient's reason for visit in their words]

HISTORY OF PRESENT ILLNESS
[Standard HPI elements — obtained via telehealth]
[Note any limitations of telehealth assessment]

REVIEW OF SYSTEMS
[Pertinent positives and negatives]

MEDICATION REVIEW
[Current medications reviewed — any changes]

TELEHEALTH PHYSICAL EXAMINATION
General: [observed via video — appearance/distress]
Vital signs: [patient-reported or from home monitoring]
[System-specific elements observable via video]
[Limitations noted: unable to auscultate/palpate]

ASSESSMENT
[Clinical assessment with telehealth limitations noted]
[Differential diagnosis if applicable]

PLAN
- Treatment: []
- Medications: [new/changed/refilled]
- Labs/imaging: [if ordered — how patient accesses]
- Referrals: []
- Education provided: []
- In-person visit needed: [yes/no — when]
- Return precautions: []
- Follow-up: [timeframe/modality]

TELEHEALTH COMPLIANCE NOTE
- Visit meets requirements for [CPT code]
- Medical necessity: [documented]
- State telehealth requirements: [met]

Note: Telehealth regulations vary by state and payer — verify current requirements

Source: https://promptzyo.com/prompt/doctor-telehealth-visit-documentation