AI documentation for
telehealth consults

Phone and video consults are a permanent part of Australian practice, and the record-keeping expectations that apply in the consulting room apply to them without change. AHPRA's registration standards, the Privacy Act's treatment of health information and the documentation that supports an MBS claim all follow the patient and the service, wherever it happens. A telehealth note that reads thinner than a face-to-face note for the same problem undermines continuity of care and stands up poorly in a compliance review.

In practice, telehealth notes often are thinner. Typing while holding a phone conversation is awkward, a video consult invites the clinician to look at the patient rather than the keyboard, and back-to-back call blocks leave no gap to write in. Ambient documentation removes that pressure by capturing the conversation itself, but it introduces mechanics of its own: the audio has to reach the capture, consent has to be handled over the line, and the note has to state a few facts that a face-to-face note never needed.

An ambient scribe drafts from the audio of the conversation, so the practical question for telehealth is whether both voices reach whatever is doing the capturing. In a consulting room this takes care of itself. On a call it depends on how the audio is routed, and checking the setup at the start of a telehealth block avoids a run of patchy drafts.

For a video consult run through a computer, the simplest reliable arrangement is to let the patient's voice play through the speakers so the microphone hears both sides of the conversation. A headset keeps the patient's voice out of the room, which means a tool that listens through the microphone will only capture the clinician's half. Some tools capture the call audio directly from the device instead, which makes headsets workable, so it is worth knowing which kind you are using before you rely on it.

Phone consults follow the same logic. A speakerphone on the desk, or a call routed through the computer with the sound playing aloud, puts both voices in the room. A handset held to the ear keeps the patient's side out of the capture entirely. Where the line itself is poor, the draft will reflect it: a dropped word in a medication name or a dose is exactly the kind of gap that review before signing exists to catch. On a bad line it is worth repeating critical details back to the patient clearly, both as good clinical practice and so they land in the capture.

The principles of consent do not change with modality, but the mechanics do. The waiting room materials that support consent in person, the poster and the practice brochure, are not available on a call, so consent for a telehealth consult is asked for and given verbally, at the start of the call and before capture begins.

Plain wording works best. Something like: 'I use a tool that helps me write my notes. It listens to our conversation and prepares a draft, which I review and sign myself, and your information is handled under the practice's privacy policy. Are you comfortable with me using it today?' That takes a few seconds of the call and covers what the patient actually needs to know: something is listening, a human remains responsible for the record, and their information is protected.

Record the consent in the note itself, the same as any other verbal consent. If the patient declines, turn the capture off and document the consult the way you always have; declining must cost the patient nothing. For regular patients a shorter reconfirmation is reasonable once the full explanation has been given, and some practices add a line about the documentation tool to their telehealth appointment reminders so the question comes as no surprise on the call.

The MBS includes permanent telehealth items, and video and phone attract separate item numbers with their own descriptors. Some services can only be claimed when delivered by video, so the modality of the consult is a billing fact as well as a clinical one. MBS Online carries the current descriptors and rules, and they change often enough that the practice should check them there rather than rely on memory.

Most general practice telehealth items also require an established clinical relationship with the practice, which in general terms means the patient has attended face to face within the previous twelve months, with limited exemptions. The individual note does not have to restate this every time, but the record as a whole should support it if a claim is ever reviewed.

An ambient scribe helps here because the whole conversation is captured, so the clinical content of the draft is rich. What it cannot do is guarantee the administrative facts. Modality, duration and consent take seconds to confirm in the draft during review, and they are exactly the details a Medicare compliance review checks the record for.

Whatever the item, the note is what substantiates the claim, and for telehealth that means recording a few things a room consult never had to state. A telehealth note should show:

• that the consult happened by video or by phone, stated explicitly
• clinical content that meets the item descriptor, the same standard as face to face
• the duration of the consult where the item is time-tiered
• the patient's verbal consent to the documentation tool, where one was used
• anything relevant to the established clinical relationship, where the item requires one

Plenty of clinic days now mix room consults with telehealth blocks, or alternate a face-to-face patient with a phone call all session. The documentation workflow should be identical across both, because a review habit only protects the record when it runs on every consult. Capture should start the same way, drafts should land in the same queue, and review and sign should be one habit regardless of how the patient attended.

Two things genuinely differ between the modes and deserve a moment when switching. The audio path changes: a room consult captures naturally, a call needs the speaker or routed audio described above, and it is easy to carry a headset from a video call into a room consult without thinking about what the microphone can now hear. The consent step changes too, from the practice's standard in-room approach to the verbal script, and the clinician needs to notice which kind of patient is next.

Telehealth blocks tend to run back to back, which tempts clinicians to leave every draft for the end of the day. Reviewing between calls, or at least at the end of each block, keeps the details fresh and the record contemporaneous, which matters for MBS purposes and for the note's weight as a legal record. Notes for phone and video patients belong in the same patient record in the practice software as every other note, so the finished record of a hybrid day looks uniform, with the modality visible in what each note states rather than in how it was produced.