Records and documentation standards
Record virtual care the same way you record any care.
What this is: clear guidance on what to document after a virtual consultation, and where.
Who it's for: registered nurses, enrolled nurses, care staff and clinical leads.
A virtual consultation is a clinical episode, and it needs a clinical record, the same as an in-person visit. Good documentation protects the resident (it keeps their care connected and informed), protects your home (it's your evidence of safe care), and supports continuity across shifts and providers. The rule is simple: record virtual care the way you'd record any care, in the same system, to the same standard.
What to record
For every virtual consultation, capture:
- Consent: that it was obtained, and what it covered.
- Participants: who took part, on both sides, including family, interpreters or trainees.
- The clinical content: the reason for the consult, the assessment, and the clinician's findings and advice.
- Outcomes and actions: any changes to medications, referrals, or the care plan, and who is responsible for follow-up.
- Any images or device outputs: stored in approved locations and linked to the record.
- Follow-up: what happens next, and when.
Where to record it
- Document in the resident's clinical record, in your usual clinical system, not in a separate or personal location.
- Store images and files only in approved systems. Don't keep clinical files on personal devices.
- Make sure the record is accessible to the team who need it for continuity of care.
Keep a consultation register (optional but useful)
Many homes keep a simple register of virtual consultations alongside the clinical record. It's a quick way to see activity at a glance, support quality review, and demonstrate your virtual care service in action. A basic register might capture:
| Field | Example |
|---|---|
| Date and time | [ ] |
| Resident | [ ] |
| Type of consult | GP round / wound review / specialist / case conference |
| Provider | [ ] |
| Outcome | Managed in place / referral / transfer |
| Follow-up needed | [ ] |
Why the standard matters
Documentation is where virtual care meets your governance and compliance obligations. Clear records support the Strengthened Quality Standards around clinical care and information management, give you the evidence to show care was safe and appropriate, and make incidents or complaints far easier to navigate. They also feed your continuous improvement: you can't review what you didn't record.
Good documentation habits
- Document promptly, while the detail is fresh, ideally straight after the consult.
- Be factual, clear and specific. Record what was assessed, advised and decided.
- Note the resident's involvement and understanding.
- Complete handover to the next shift so actions don't fall through.
- Close the loop: record when follow-up actions are actually done.
Tie it back to the workflow
Documentation isn't a separate task, it's the final stage of the consultation workflow. The "after the consultation" steps in the core workflow guide build it in: record, hand over, follow up, and reset. Treating documentation as part of the consult, not an afterthought, is what keeps it consistent.
Need help?
- Visionflex support: visionflex.com/support | support@visionflex.com | +61 2 8914 4000 (9am to 5pm AEST)
- See also: Before, during and after a virtual care consultation and the Privacy, security and medico-legal checklist.
This is general guidance, not legal advice. Follow your home's documentation and records policies.
Visionflex acknowledges the Traditional Custodians of Country throughout Australia and pays respect to Elders past, present and emerging.