Telehealth Visit Note Template

This template is a normal SOAP note wrapped around a virtual encounter record, the block of fields that never appears on an in-person note. It captures the patient's physical location at the time of service, the clinician's site and whether they are licensed in the patient's state, the modality and platform, consent to telehealth and identity verification, and anyone else present on either side of the screen. The objective section is built for what a remote exam actually is: observed findings, patient-reported measurements with the device named, and a dedicated field for the limitations of the remote examination and whether they mattered. An escalation field records whether in-person or urgent evaluation was advised.

The payment logic sits in the location field. CMS uses POS 02 for telehealth provided anywhere other than the patient's home and POS 10 for telehealth in the patient's home, and since January 1, 2024, services furnished to patients at home are paid at the higher non-facility rate. Where the patient sat during the visit is therefore a payment determination, and the note is where it gets established. The template also carries the payer split that causes most telehealth denials: Medicare identifies telehealth through place of service, while most commercial and Medicare Advantage payers still want modifier 95 for audio-video and 93 for audio-only. Current flexibilities run through December 31, 2027, and the footer says so. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.