A phone or video consult can leave a clear clinical record, even when parts of an assessment are unavailable remotely. The challenge is making the evidence, its limits and your decisions understandable to the next clinician. For Australian GPs and other medical practitioners, good telehealth documentation connects the usual consultation record with the details that explain how remote care was delivered.

What telehealth changes in the clinical record

The ordinary documentation standard still applies. The Medical Board of Australia’s medical records guidance calls for accurate, current, legible records covering relevant history, findings, investigations, diagnosis, information given, medicines, referrals and management. Records should support continuity of care and be made at the time of the encounter or as soon as possible afterwards.

The Board’s telehealth record-keeping guidance says doctors should also record the technology used, technical issues, and consent from all participants for digital recording or uploads to digital health infrastructure such as My Health Record.

Keep the different kinds of obligation separate:

• Professional guidance: the Medical Board’s code and telehealth guidelines apply to doctors.
• General-practice guidance: Royal Australian College of General Practitioners (RACGP) recommendations add GP-specific detail about documenting phone and video consultations.
• Legal and service-specific requirements: record handling and retention depend on the applicable jurisdiction and care setting.
• Practical recommendations: risk-based documentation prompts help explain the encounter. They are not a mandatory national note form.

You can retain your normal note structure. As a practical clarity prompt, keep the encounter date, relevant time and responsible clinician identifiable in the record. Our clinical note-writing guide covers the foundations; the remote details belong alongside the history, assessment and plan they affect.

Record the method, identity and people involved

Identify whether the consult was by phone or video. If the method changed, record that change and any clinical consequence, for example, a failed video connection meant a planned visual assessment could not proceed.

The Board’s patient identity guidance says you should confirm, to the best of your ability, the identity of the patient and others present. We recommend recording how identity was established where needed, using your practice’s identification procedure.

Record who took part and distinguish each person’s role. A carer providing history, an interpreter supporting communication and another clinician contributing an examination are different sources of information. Make it clear whose account or findings informed your assessment.

When location and callback details matter

We recommend confirming the patient’s current physical location and a reliable callback route when they affect emergency response, reconnection or a jurisdiction-specific obligation. Record the details needed to act on that plan. A home address already in the record may differ from where the patient is during the call.

This is a risk-based recommendation. Neither Medical Board guidance nor RACGP guidance lists current physical location as a universal required field in every note.

Distinguish reported information from observed findings

The reader of a note needs to understand how you know something. For remote consults, we recommend keeping these evidence sources distinct:

For example, “patient reports no ankle swelling” and “no peripheral oedema on examination” convey different evidence. Likewise, “patient reports a home blood pressure reading of 132/84 this morning” identifies the source more clearly than an unqualified blood pressure entry.

These are examples of documentation precision, not instructions for assessing those conditions. Use the detail that matters to the clinical question. A results discussion and an assessment of a new symptom will need different records.

Connect assessment limits to reasoning and action

Video does not reproduce every hands-on examination. The Board’s telehealth suitability guidance says doctors should continuously assess appropriateness and arrange in-person care when necessary.

For documentation, the useful question is what a limitation meant for your decision. Avant’s medico-legal documentation checklist recommends recording assessment limits, clinical reasoning and management, including the need for an in-person examination. This is general medico-legal information from a medical-indemnity provider, rather than professional advice or a statutory checklist.

We recommend linking four elements when a limitation matters: the evidence available, what remained unassessed, how that affected your reasoning, and the action agreed with the patient.

“Assessment limited by telehealth” leaves the next clinician guessing. A more useful account identifies the missing information and the response. For example, a note might explain that repeated video freezing prevented an adequate view of a skin change, and that an in-person appointment was arranged. The timing and destination should reflect the actual clinical decision.

Record relevant measures or assessment tools used, and distinguish a finding you could not assess from a finding that was absent. Do not carry forward a normal examination statement from a previous consult or default text when that examination did not occur.

RACGP’s technical malfunction guidance calls for documenting faults that may have compromised safety or quality. As a practical step, describe their impact, such as lost information, an unavailable observation or a change of consult method.

Keep this proportionate. A remote consult does not need an exhaustive list of every examination you did not perform. Include the gaps that affected assessment, confidence, management or the need for another review.

Make the plan, safety-netting and follow-up usable

The plan needs to preserve the decision and what happens next. Avant recommends discussing what the patient should do if their condition changes, worsens or does not respond. Its follow-up recommendations provide a practical basis for recording that discussion.

Safety-netting means giving the patient a route to further care if the situation develops. As a practical approach, document:

• the relevant warning symptoms or changes discussed;
• the action advised, including where to seek help and how urgently;
• what to do if the expected improvement does not occur;
• any communication barrier or misunderstanding that affected the agreed plan.

“Safety-netting given” does not preserve that information. Record the advice actually provided, at a level of detail suited to the problem. Do not add a standard list of red flags that was never discussed.

For planned follow-up, make the arrangement operational: the reason for review, intended timing, who will organise it, and any outstanding result, referral or in-person assessment. Distinguish a recommendation from an appointment already arranged. If the patient declines a proposed next step, record the discussion, their decision and the alternative plan agreed.

The Australian Health Practitioner Regulation Agency (AHPRA) continuity guidance addresses follow-up, handover and communication with relevant practitioners when indicated, appropriate and with patient consent. The timeframe comes from the patient’s clinical needs and applicable service procedures; there is no single follow-up interval for every remote consult.

Keep the different consent decisions separate

One entry saying “consent obtained” can obscure what the patient agreed to. Consent to a phone or video consultation, another person’s presence, digital recording and use of an AI scribe are distinct decisions.

For GPs, RACGP telehealth guidance calls for documenting verbal informed consent to phone or video consultation, details of other people present and explicit consent for their presence. Recording and digital-upload consent should remain identifiable as separate decisions. These requirements do not establish one universal consent form or legal basis for every workflow.

AHPRA’s telehealth consent guidance says practitioners should explain what to expect, including recording or use of an AI scribe, and obtain informed consent. The patient’s agreement to speak by phone alone does not document agreement to AI audio capture.

For a documentation tool, follow the practice’s notice and consent process and obtain and record any consent required for that specific workflow before capture begins. Our AI-scribe consent guide covers that separate issue in more detail.

Enter the note securely and apply the right retention rules

Return the final note to the patient’s clinical record promptly. If a GP cannot access that record during the consult, RACGP says a secure, consistent interim recording method must be established. The consulting GP is responsible for adding the information to the electronic record as soon as practicably possible. Interim record guidance keeps that responsibility explicit.

As risk-assessed practice, use an approved clinical system or interim process, keep access limited to authorised people, and preserve the correct patient and encounter details when transferring the note. A draft left in a separate app or personal document is not a completed record-entry workflow.

The Medical Board’s record amendment guidance calls for secure records and dated changes or additions, including in electronic records. As a practical control for a late entry, preserve the distinction between the encounter date and when you added information; make corrections through the record system’s amendment process.

Under Australian Privacy Principle 11, covered entities must take reasonable steps to protect personal information. The Office of the Australian Information Commissioner (OAIC) explains in its security guidance the duty to destroy or de-identify information no longer needed for a permitted purpose, subject to exceptions including legally required retention and Commonwealth records. That duty does not set a national clinical-record retention period or authorise early deletion.

Retention depends on the applicable law, record type and setting. For example, NSW’s private-provider retention guidance applies to private health providers in NSW, not public sector agencies or every Australian practice. Apply your service’s lawful retention and disposal schedule to the clinical record and any associated material.

Use drafting support without losing the clinical context

Your judgement supplies the assessment, reasoning and plan. An AI scribe can help prepare the record, but a draft still needs clinician review and editing and sign-off before filing.

Our clinical AI platform, Lyrebird, supports phone and video audio capture and structured draft notes. For computer video consults, shared audio from a selected call tab is available in Chrome and Edge. Phone capture can use speakerphone and a microphone in a private setting, with the required consent process completed before capture.

In review, retain the distinctions that matter remotely: reported versus observed findings, what was unassessed, your reasoning, and the advice and follow-up actually agreed. Add relevant decisions or observations that were not spoken aloud. Lyrebird does not establish identity or location, complete a physical examination, decide whether telehealth is suitable, or automatically satisfy documentation obligations.

The finished record should let another clinician understand both the care delivered and what remains to be done.

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