Documenting virtual care in your clinical system

What this is: practical guidance on documenting virtual care consultations in your clinical record system, so your records are consistent, complete, and meet your professional and legal obligations.

Who it's for: nurses, GPs, allied health professionals, clinic managers, and quality leads.

The same standard applies

Virtual care documentation follows the same professional and legal standards as in-person care. AHPRA, the medical boards, and nursing and midwifery boards are clear on this: the mode of delivery does not change the standard of record keeping. If you would document it in a face-to-face consultation, document it in a virtual one.

The key difference is that a virtual consultation often involves two locations and two sets of records. Getting this right from the start avoids gaps, duplication, and confusion about who documented what.

What to document for every virtual care session

At a minimum, record the following for each virtual consultation:

Identity and participants. Who was the patient? Who was the clinician? Who else was present (onsite support staff, family member, carer, interpreter, trainee, observer)? Record this at the start so the record reflects who was in the room on both sides.

Consent. Record that consent was obtained for the virtual consultation. A short statement is enough: "Patient consented to virtual care consultation." If the patient declined, or if consent was obtained from a substitute decision maker, note that and the reason.

Mode of delivery. Note that the consultation was delivered by virtual care (video consultation using Visionflex, or video with peripherals, or audio-only if failover was used). This matters for billing, audit, and clinical context.

Clinical content. Document the same clinical information you would for an in-person consultation: presenting issue, history, examination findings, assessment, plan, medications, referrals, and follow-up. If peripherals were used during the session (for example, digital stethoscope, wound imaging, vital signs), note what was used and the findings.

Images and device outputs. If images were captured (wound photos, skin images, otoscope images) or device outputs were recorded (ECG trace, vital signs readings), note where they are stored. Ideally, they should be in the clinical record alongside the consultation note. If they are stored in the Visionflex platform (ProEX), note that and ensure the record links or refers to them.

Follow-up actions. Record referrals, scripts, orders, and next appointment or review date. Assign actions clearly so nothing falls between the cracks.

Escalation or incident. If escalation occurred during the session, document the trigger, what happened, who was contacted, and the outcome. If a safety or privacy incident occurred, record it in both the clinical record and your incident management system.

Where to document

The clinical record system your organisation uses is the single source of truth. This might be a GP clinical system, a residential aged care clinical system, a community health record, or a hospital electronic medical record. The principle is the same regardless of which system you use.

The onsite clinician or support staff documents in the patient or resident record at the site. This captures consent, participants, onsite observations, peripheral findings, and follow-up actions.

The external clinician (GP, specialist, allied health) documents in their own clinical system as they would for any consultation. They should also communicate key findings and actions back to the onsite team, either verbally during the session or via a written summary.

Avoid splitting the record. Do not put half the information in the clinical system and half in an email, a text message, or a sticky note. If images or device outputs are captured in ProEX or another platform, reference them in the clinical record so the full picture is in one place.

Tips for consistent documentation

Use a template or structured note. If your clinical system supports templates, create a short virtual care consultation template with prompts for consent, mode, participants, and follow-up. This saves time and ensures nothing is missed. Even a simple free-text structure works:

• Mode: Virtual care (video) via Visionflex
• Consent: Confirmed verbally, recorded
• Present: [Patient], [Onsite RN], [External clinician], [Family member]
• Presenting issue:
• Examination / peripherals used:
• Assessment:
• Plan:
• Follow-up:

Tag or flag virtual care consultations. If your system supports consultation types, activity codes, or tags, create one for virtual care. This makes it easy to pull activity reports and demonstrate usage to your board or funder without manually counting sessions.

Set expectations for external clinicians. As part of onboarding, confirm with each external clinician how they will communicate findings back to your team. Agree whether they will send a letter, update a shared system, or provide a verbal summary during the session. Do not assume they will know your documentation process.

Audit regularly. Spot-check five records per month. Confirm that the session was documented, consent was recorded, participants were noted, and follow-up actions were captured. The Monthly BAU Review Pack includes a documentation compliance prompt for this.

Handling images and device outputs

Images and data captured during a virtual care session are health information. They must be handled under the same privacy and record-keeping requirements as any other health record.

Store in approved systems only. Images and device outputs should go into the clinical record, an approved image management system, or the Visionflex platform (ProEX) if your organisation has approved that for clinical storage. Do not store images on personal devices, desktops, personal cloud storage, or messaging apps.

Label clearly. Each image or output should be linked to the patient, the date, the session, and the clinician. Unlabelled images in a shared folder are a privacy and clinical risk.

Retention. Retain images and device outputs according to your organisation's records retention policy and applicable legislation. Health records retention periods vary by jurisdiction and setting.

When things go wrong with documentation

If you discover a documentation gap (a session that was not recorded, consent that was not noted, images that were stored in the wrong location), fix it as soon as you find it. Make a late entry in the clinical record noting the date and reason for the late documentation. If a privacy issue is involved (images in the wrong location, record shared with the wrong person), follow your privacy incident pathway.

Do not backdate entries or alter existing records without a clear audit trail.

Need help?

Your Visionflex team is here to support your rollout, training and day-to-day use.

Visionflex support: visionflex.com/support | support@visionflex.com | +61 2 8914 4000 (9am to 5pm AEST)

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