This article is a short guide to help Telehealth On Demand doctors write clear, concise patient notes that support continuity of care. It outlines why notes are important, what details to include, and provides examples and templates you can use to save time.
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In this article |
Why patient notes matter
When you see a patient via Telehealth, you may be the only doctor they interact with in that episode of care. If the patient consents during the booking process, your notes are shared with their usual GP to promote continuity of care. If requested, the notes are also shared with the patient to help them better understand their care plan and keep a personal record of the consultation.
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If a patient has indicated they consent to having notes shared with their GP or they would like a copy for themselves, it is mandatory to enter these notes into the Sidebar during or shortly after the consult. For further information about where to enter the notes, please see: Practitioner Guide: Telehealth On Demand. |
HotDoc's expectations
The Australian Health Practitioner Regulation Agency (AHPRA) requires all practitioners to keep accurate, up-to-date, factual, and legible health records. Records should be objective and respectful, include relevant clinical history, treatment and advice, clearly identify who provided the service and when, and document consent where required. For the full Code of Conduct, see AHPRA: Managing health records. |
Clear, concise notes not only support safer, more coordinated treatment for the patient but are also part of your professional responsibility under our Practitioner Code of Conduct.
Our expectation is that your notes are sufficient to give the patient’s regular GP a clear understanding of what occurred during the consultation.
| When using the HotDoc Dialler, notes can be entered straight into the Sidebar during the consult. Writing the notes as you go is a great way to save time. |
What to include
Your notes should be brief but detailed enough that another GP can understand what was discussed, what was decided, and any follow-up needed.
Aim to include:
- Your name and role
- The reason for the consult (symptoms, request, or concern)
- Any relevant patient history
- Assessment (your impression, working diagnosis, or ruling out of key risks)
- Plan (treatment given, advice provided, follow-up recommendations)
How to structure your notes
| You’ll naturally find a note-taking style that works best for you, and we don’t expect everyone to use the same format. As long as the main points of the consultation are clearly captured, you’re encouraged to record your notes in the way that feels most efficient and natural to you. |
A few common ways to structure notes can be found below.
ISBAR style:
I — Identify: Your name and role
S — Situation: Presenting complaint or reason for consult
B — Background: Relevant history or context
A — Assessment: Your impression or working diagnosis
R — Recommendation: Treatment given, advice, and follow-up
One-line summary style:
- [Your name and role]. [Age/sex] with [symptom/concern]. [Any relevant history]. Impression: [diagnosis/likely cause]. Plan: [treatment/advice/follow-up].”
Examples
ISBAR style:
Telehealth On Demand appointment between Dr Frederick Findacure and John Doe, 40M
Cough and mild shortness of breath for 5 days
Non-smoker, no significant medical history, COVID vaccination up to date
Likely viral upper respiratory tract infection, no red flags
Recommended supportive care, rest, fluids. Advised to see GP if symptoms worsen or persist >7 day
One-line style:
27M with cough and mild shortness of breath x5 days. No red flags. Impression: viral URTI. Plan: supportive care, fluids, GP review if no improvement.
Poor note:
“Cough.”
(Too vague, no context, assessment, or plan — not useful for continuity of care.)
Troubleshooting
I'm trying to copy and paste the patient notes I've entered in our Practice Management System, why is it not letting me paste them in the Sidebar?
This can happen when using a Remote Desktop Service (RDS) and it is not configured correctly. When accessing your RDS, please ensure the Clipboard option is set to Bidirectional.
Why is there nowhere to enter notes in the Sidebar?
If you're not seeing the notes section, it will be because the patient has not elected to receive the notes or send them to their usual doctor. In this case, you should enter the appointment notes into your practice management software like usual, however, there is no need to enter them into the Sidebar.