Page 11 - Telemedicine - Essentials of Virtual Care Delivery Part Two

SVMIC Telemedicine: Essentials of Virtual Care Delivery

Documentation Requirements

Documentation is the cornerstone of defense should your

care be challenged. To reduce liability, physicians and other
providers should take detailed notes and keep records that

demonstrate: 1) establishment of the patient’s agreement to
and understanding of the telehealth relationship; 2) adequate

assessment by the physician of the patient; and 3) provision of
accurate health history by the patient.

It is your responsibility to document, secure, and maintain
records for a virtual visit as you would an in-person encounter.

Some states require specific items be documented in a
telemedicine encounter; for example, Tennessee requires

that the type of technology utilized for the encounter must
be specified in the encounter note. Since any later question

or dispute about the course or outcome of treatment would
involve determining the setting (i.e., virtual or in-person) of the

encounter, it should almost go without saying that the record
ought to include:

• Evidence of the consent to the telemedicine encounter

should be properly documented. Some states require
specific details in the consent as well.

• Identification of all individuals present and/or participating
in the visit, including scribes, assistants, technicians,

interpreters, family members, etc.

• The geographic location of each participant.

• The technology employed, including the communication
medium.

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