August Edition 2021
Inside This Issue
Seven Tips for Telehealth Clinical Documentation By Sue Boisvert, BSN, MHSA Patient Safety Risk Manager II The Doctors Company
T St. David’s Healthcare Launches New Graduate Medical Education Programs See pg. 11
INDEX Legal Matters....................... pg.3 Oncology Research......... pg.4 Mental Health...................... pg.6 Healthy Heart....................... pg.8
Racial Disparities in Prostate Cancer See pg. 12
he standards of care for telehealth are identical to those for onsite medical care: Medical and dental professionals must practice with the same level of skill and expertise as qualified practitioners in the same specialty under the same circumstances. State regulations and associated rules define what constitutes telehealth, third-party payer contracts outline medical necessity expectations and the services that qualify for reimbursement, your organization’s policies and procedures define practice expectations, and case law clarifies the interpretation of all these standards. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and supporting your defense in the event of a professional board complaint or medical professional liability claim. The following seven tips outline unique considerations for documenting telehealth care: 1. Modality. Specify clearly in the medical record what modality of telehealth is being used. Examples include “secure interactive audio-video session using Skype,” “medication management visit conducted by telephone,” or
“asynchronous diagnostic test follow-up by portal/text/email.” 2. Geography. Note the patient’s physical location and geography.
on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form if used. Find our sample Telehealth Informed Consent form on our Informed Consent Sample Forms page. 4. Identity. Confirm the identity of new patients by asking them to hold a photo ID close to the camera. Document confirmation of patient identity. Patients also have the right to ask for provider identification. 5. Appropriateness. Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Evaluate and address
Following these seven tips can help you ensure t h at you r telehea lt h documentation is patient centered, comprehensive, and effective. For example, including “at her home in Tennessee” is important for billing purposes and for determining venue in the event of a regulatory or professional liability action. Also include the provider’s location (“clinic name and city” or “home office and city”) in the documentation. 3. Informed consent. Advise patients before asking them to consent to treatment by telehealth—about the unique risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based
see Telehealth...page 14
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