Telehealth and Documentation

Submitted by admin on Fri, 04/03/2020 - 09:09

We recommend that you use your Telehealth platform to make a recording of all Telehealth visits for the following reasons:

  • Informed Consent - you want to record that the patient understands that the visit is a Telehealth visit and has limitations as compared to an in person visit (you are not physically examining the patient). Since the patient is not present and can not sign a form, having this consent and acknowledgement needs to be obtained verbally and recorded.
  • Payment - Many of the Telehealth codes are based upon time spent. With a recording you have a definitive record of the amount of time spent with the patient
  • Payment - Many payers have indicated they will pay for Telehealth services but not all. Have your patient acknowledge that they understand if the visit is not covered they are responsible for payment
  • Identification - Especially for new patients, you want to have the patient hold up a photo ID as well as their insurance cards so that you can ensure that the individual you are speaking to is who they claim to be and that they are providing you with valid insurance information
  • Risk Management - Many computers have tools that allow for a user to capture their screen. You can be sure that at least some patients are making a recording of the Telehealth session. Should there be a future malpractice claim associated with that patient and they can produce a full recording of the session while you can not this may hurt your defense teams ability to defend you in a malpractice action.
  • Completeness - When you record the session, you can simply insert the recording into your record and then make a short note that references the recording. Your notes will still be complete but you will need to spend much less time documenting the visit as you have the recording of the visit as part of the medical record.