Background and objective: Data are limited that establish the clinical reliability of telemedicine in evaluating children who are seriously ill. Evaluation of a seriously ill child poses a challenge in that telemedicine is primarily visual, without the ability to perform a "hands-on" physical examination. Previous studies evaluating observation in assessing febrile children and children in respiratory distress have validated observation as both predictive and reliable in detecting underlying illness. The purpose of this study was to determine the interobserver reliability of telemedicine observations, compared with bedside observations, in assessing febrile children and children in respiratory distress. Methods: Children 2 to 36 months old presenting with a fever were evaluated by using the Yale Observation Scale; patients aged 2 months to 18 years presenting with respiratory symptoms were evaluated by using the Respiratory Observation Checklist, a list of observational signs of respiratory distress derived from validated studies and developed specifically for the present study by the authors. Telemedicine communication used commercially available tablet devices that provided 2-way, live-streamed images with audio. Results: A total of 132 febrile subjects were evaluated by using the Yale Observation Scale. Strong agreement (Pearson's correlation coefficient, 0.81) was found between bedside and telemedicine observers. A total of 145 subjects were evaluated by using the Respiratory Observation Checklist. Excellent agreement between bedside and telemedicine observers was found for the impression of respiratory distress (κ = .85) and good agreement (κ > .6) for the majority of the remaining components of the checklist. Conclusions: Telemedicine, using commercially available telecommunications equipment, is reliable in the assessment of febrile children and children with respiratory distress.