Page 13 - Telemedicine - Essentials of Virtual Care Delivery Part Two

SVMIC Telemedicine: Essentials of Virtual Care Delivery

care is going to be generally the location of the patient. So, if

you have a patient who is not located in the same state you are
in, the care is occurring in another state, then that state may

have different medical record retention requirements.

Regardless of any documentation regulatory requirements, it
should be abundantly clear in any visit note that the encounter

was by way of telemedicine. While it is obvious at the time of
the visit, unless the medical record is properly documented that

the visit was by way of telemedicine, the provider may have a
difficult time explaining why a standard portion of an in-person

visit was not performed if the note appears to be same as the
other in-office visit notes.

Finally, while documenting follow-up plans and
recommendations is an expected part of good practice in any

context, it is especially important for telemedicine encounters.
Treatment at a distance requires particular attention to handoffs,

transitions, and continuity of care.

Informed Consent Requirements

Under the laws and regulations of many states, it is a well-
established tenet of medicine that physicians must obtain

the patient’s consent for treatment. That’s the same for
3
telemedicine as for a face-to-face visit. It is recommended that

medical groups develop a specific telemedicine consent form
for their practice. A telehealth informed consent form can be

3 The concept and practice for obtaining consent to treat by way of telemedicine is analogous
in many ways to obtaining specific informed consent for a surgical procedure or prescribing
a new high-risk medication. Risks, benefits, and alternatives must be reasonably explained
to give the patient enough information to make an intelligent decision about whether to
undergo a particular procedure or initiate a high-risk treatment plan. Likewise, it is important
that patients understand the unique considerations associated with receiving care by way of
telemedicine.

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