If you have to treat a patient without access to records, here's how to best document all of the necessary information.

Posted in Coronavirus on Thursday, April 30, 2020

Many practices are scrambling to incorporate telemedicine in order to continue treating patients while fulfilling social distancing requirements. But what if you need to treat a patient without having remote access to your complete records?

In an ideal situation, you would only treat patients when you can review their records. However, under today’s circumstances, you may not have that option. These suggestions will help you maintain your own records while treating patients to the best of your ability.

As always, document, document, document. This is the standard even in normal circumstances but is even more essential when functioning without record access. You are relying on the information and perception the patient is providing, so, documentation of your conversation becomes even more critical. Use quotes to capture what the patient tells you.

Process

1. Collect the patient’s demographics and document them
   • Name, age, gender, phone number
2. Inform the patient that you do not have access to their most recent health history and are thus are relying on what they are providing you.
   • To reduce frustration and potential anxiety on the part of the patient, advise the patient upfront that you do not have access to their records because of XYZ and therefore will be asking health history questions.
3. Ask the patient to have pen/paper available to record your instructions and to participate in the call.
4. Have the patient verbally state back to you that they understand your limitations (think about how flight attendants those in the emergency row verbally state they can help). Document their response with something to the effect that the patient “has verbally stated they understand and agree to proceed with the visit.”
5. Obtain a brief history from the patient of what prompted the call today:
   • Chronic health problems, medications, OTC remedies, recent visits/hospitalizations
   • When symptoms first presented
   • What treatment they have been using/doing so far (what, when and how) and how is that working?
6. Identify chief complaint using opened ended questions, such as “tell me…”
   • Have patient describe the symptoms. Document the why or why-nots of a telemedicine visit for this health concern.
7. Ask the patient what other questions they have.
8. Document the questions and your responses.
9. After the “examination,” but before ending the conversation, have the patient repeat back to you all of the instructions and advice you provided (and they hopefully wrote down).?Document that the patient has done this as a confirmation of their understanding of the visit.
10. Reiterate call-back instructions.
11. Create a document to help you preserve the details of the conversation with all the information that would normally be in your records, including date, time, who called, relationship with the patient, confirmation of identity of the patient, advice provided.