Headings
Visit type · Patient location · Chief complaint · History · Observed examination · Assessment · Plan · Follow-up
When to use it
Use this for video or phone visits, where the note has to record how the visit happened and where the patient was at the time. The exam section is for what you could actually see or hear, which keeps the record honest about its limits. Any clinical problem fits, but the format is built around remote care rather than a single diagnosis.
Example
Fictional example
Visit type
Video visit, audio and video. Patient consented to telehealth.
Patient location
Home, same state as clinician.
Chief complaint
Burning with urination for 2 days.
History
S.B., 34. Frequency and urgency. No fever, flank pain or vaginal discharge. Not pregnant. Last urinary infection 2 years ago.
Observed examination
Alert, speaking in full sentences, no distress. No visible discomfort when changing position. Could not assess costovertebral tenderness.
Assessment
Uncomplicated cystitis.
Plan
Nitrofurantoin 100 mg twice daily for 5 days, sent to her pharmacy. Fluids. Phenazopyridine 200 mg three times daily for 2 days as needed.
Follow-up
In-person visit if fever, back pain or no improvement in 48 hours.