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Electronic Medical Records and Documentation in Telemedicine

By Jonathan Terry, DO, ABIHM to Telemedicine


Electronic Medical Records and Documentation in Telemedicine

Our guest on Healthcare Matters is Jonathan Terry, DO, ABIHM. Dr. Terry is an osteopathic physician and surgeon and general psychiatrist who uses telemedicine extensively in his practice. Dr. Terry practices at the United Health Centers of San Joaquin Valley, which recently won the 2016 Health Delivery, Quality and Transformation Award from the American Telemedicine Association.In Part V of our series, Physician Focus: Telemedicine, we ask Dr. Terry about the use of electronic medical records and documentation in telemedicine.

This is only one of many questions we asked Dr. Terry about telemedicine. Check them all out here:

  1. Defining Telemedicine
  2. Ways the Affordable Care Act Affects Telemedicine
  3. Four Advantages of Telemedicine
  4. Informed Consent and Telemedicine
  5. Electronic Medical Records and Documentation in Telemedicine
  6. Legislative Challenges to Telemedicine
  7. Telemedicine Reimbursement Rates
  8. Physician Focus: Telemedicine


Mike Matray: You were talking about an electronic informed consent form, and I assume that would be filed away in the electronic medical record. How do best practices for entering data into a medical record when it’s acquired via telemedicine as opposed to face-to-face encounter differ?

Dr. Terry: You know documentation with telemedicine, even though in some ways we’re taking short cuts a long distance, that sort of thing, documentation is certainly something we can’t take any short cuts with. Best practices for telemedicine include documenting not only that the practice occurred of course by telemedicine, but also in many sort of third party payer situations, why was telemedicine used? Commonly this might be because of no local provider being available. Today if you want the service, this is the way we’re offering it.

It’s also a good idea to document each encounter of course that the patient has renewed essentially their informed consent to telemedicine, and that the provider or staff have explained the risks and limitations of the process of telemedicine itself. Many medical records of course now allow for electronic submission of our charges, of our ICD-10 diagnoses and CPT codes, and there may be additional procedure codes as well that should be documented and entered at both the origination, usually where the patient is at and the receiving, where the provider is at, sites.