Telehealth Documentation

Due to the COVID-19 pandemic, existing Deliver Health Transcription clients may need a way to optimally document their Telehealth interactions with patients. Nuance is offering an option to facilitate the inclusion of telehealth notes into your existing dictation/transcription workflow.

 

Dictation and Transcription

 

 

·         Utilizing a Normal

·         Identify which document type you will want to utilize for this workflow. 

o    Recommendations:  Phone Note or Office Note; however, your organization may determine a different document type should be utilized. 

o    Note:  Think about the turnaround time for specific reports and what may be needed for your Telehealth reports and try to choose a document type that has a similar turnaround time.

·         Determine if your organization will utilize this standard Telemedicine normal text shown below or adjust/create your own.

o    Standard Text: 

TELEMEDICINE VISIT NOTE

 

I connected with [______] on [______] at [______] by a video enabled telemedicine application and verified that I am speaking with the correct person using two identifiers.

 

I discussed the limitations of evaluation and management by telemedicine and the availability of in-person appointments. The patient expressed understanding and agreed to proceed.

 

History of Present Illness:

[Type here]

 

Observations/Objective:

[Type here]

 

Assessment and Plan:

[Type here]

 

Follow Up Instructions:

[Type here]

 

I discussed the assessment and treatment plan with the patient. The patient was provided an opportunity to ask questions and all were answered. The patient agreed with the plan and demonstrated an understanding of the instructions.

 

The patient was advised to call back or seek an in-person evaluation if the symptoms worsen or if the condition fails to improve as anticipated.

 

I provided [____] minutes of non-face-to-face time during this encounter.

 

·        Utilize the Outlook email template in the files section below to request this workflow. If you have any issues utilizing the email template, please contact esone.support@deliverhealth.com .  

·        Provider Communication:  After receiving confirmation the normal is available within eSOne, please ensure you communicate out with your providers the following:

o    Advise them which work type they should utilize for documenting their Telehealth notes.

o    At the beginning of dictation, they should request the “<Telemedicine> normal be inserted”.
 

NOTE: Utilization of a normal on an existing document type will NOT allow for reporting specific to usage of said normal.