Step 5: Documenting in EHR
Video visits can facilitate many aspects of a physical exam. With the help of a family/caregiver using a webcam and flashlight on the other end, you can make meaningful observations. Documenting the visit is important for billing. Here’s sample documentation from a video visit:
Sample Physical Exam Documentation
General: Alert, well-appearing, interacting in an age-appropriate manner
Skin: No pallor, rash or ecchymosis (parts visible)
Head: Normocephalic/atraumatic. Anterior fontanelle appears flat, soft, and non-bulging (caregiver observation)***
Eyes: PERRL (observed construction using light source). EOMI (follows objects in four directions). Sclera are white, not injected. Conjunctivae are pink, not erythematous or pale. Lids and orbits are normal appearing. No ocular drainage visible on lids/lashes.
Ears: External ears appear normal, no obvious swelling or erythema. No visible drainage from ear canals. Manipulation of tragus/pinna does not elicit pain.
Nose: No obvious rhinorrhea or nasal discharge. Nares patent. Breathing through the nose observed with closed mouth.
Mouth: Moist oral mucosa. No oral-mucosal lesions visible with light shown in mouth. Uvula appears midline, tonsils symmetric, grade I/II/III+, pink without exudate.
Neck: Normal flexion, extension, rotation. No visible external masses.
Cardiovascular: No cyanosis, mottling or pallor. Capillary refill < 2 seconds.
Respiratory: Normal work of breathing. No nasal flaring, subcostal, suprasternal or intercostal retractions. No audible stridor or grunting. No coughing. Pt speaking in sentences without difficulty (if verbal)***.
Gastrointestinal: Abdomen appears flat and non-distended. No tenderness apparent with supervised palpation to four quadrants of abdomen. Stool normal appearing.
Musculoskeletal: No visible deformities or swelling of joints or extremities. Moving all four extremities normally. Bearing weight without difficulty. Normal gait observed.
Neurological: Alert, interactive and age appropriate. Symmetrical facial movements, no nystagmus, no amblyopia. Verbalizes normally with normal voice quality. Normal activity and strength. Coordination grossly normal. Observed walking, reaching across midline, grasping objects.
Some markets also require a standard phrase, with details of how the telehealth visit was conducted, be included at the end of your note. If your state/market requires this, here is a sample phrase that could be used:
The following modality (e.g., live audio/video connection, telephone) was used to conduct this live telehealth visit: _____.
The patient attended remotely from [Location] while the physician attended from [Location]. Prior to the appointment, the patient or their guardian provided us with informed consent to conduct this telehealth visit. On the day of this telehealth visit, I spent a total of ___ minutes on this patient’s care. This total includes medical decision making and preparation before the visit, the time spent examining the patient and any post-visit care coordination conducted on the day of the telehealth visit.