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A Turn Toward Virtual: How Has Medical Documentation Changed with Telemedicine?

How Has Medical Documentation Changed with Telemedicine?

The screen between. Since the onset of the Covid-19 Pandemic, we’ve all become more accustomed to computer screens stepping in as a replacement for many of our in-person interactions. Whether it’s non-stop Zoom calls for work, staying up-to-date with your community via online meetings or even enjoying a virtual concert from your own home, our lives have become more technology-based than ever before.

And then there is telemedicine. Defined by WebMD as “All of the ways you and your doctor can use technology to communicate without being in the same room,” this particular way of practicing medicine has seen rapid growth of late.


Telemedicine and Social Distancing Come Together

While telemedicine was around long before March 2020, it has never been more prominent than it is right now. As the world continues to find its way through the global pandemic, social distancing and virtual connections have become our new way of life.

As an article Academia explains, the use of technology in times like these allows for clinicians to safely heal at a distance: “In e-healthcare, telemedicine provides a new means to support and promote long-distance clinical care, education, and healthcare, from first response to recovery with low cost and extensive coverage.

“Public administrations around the world, such as Australia, the USA and the UK, are investing in telemedicine to manage COVID-19, with the specific aim to reduce the volume of patients interacting with emergency departments and, in turn, halt the spread of the virus.”

But, as is often the case, where there is progress, there is a downside. For clinicians who are practicing telemedicine, that downside comes in the form of even more documentation.

As we’ve previously discussed, increasing demands of documentation have contributed to the deterioration of work-life balance for clinicians. Unfortunately for clinicians, documenting telemedicine encounters means even more time in front of the computer screen.


Adding More Documentation to an Already-Full Plate

In addition to what is already mandatory with a typical, in-person visit, the documentation of an online encounter must also ensure that the medical records support the telemedicine services. An article Security Health Plan explains what those additional requirements include:

  • “Method of telehealth (e.g. secure two-way interactive video connection, phone call, etc.)
  • Provider location (e.g. clinic [city/name], home, other)
  • Listing all clinical participants, roles, and actions (e.g. applicable when member presents at a clinic with MD at another location)
  • Member location (e.g. clinic [city/name], home, etc.)
  • Time spent in medical discussion must be explicitly documented to support the procedure code billed, including start/stop times, if required for the service
  • Patient consent (providers must document confirmation that a member agrees to receive services via telehealth; verbal consent to receiving telehealth is an acceptable method but must be documented in the medical record”


Other Time-Consuming Telemedicine Tasks

Beyond just the extra documentation demands are other inconveniences that must be considered when it comes to telemedicine. One pain point in particular? Vitals.

What was once such a simple task for a clinician to run through now requires many of them to train their patients on how to accurately record everything from their own temperatures, to their pulse rates, weight and blood pressure. There is a learning curve, to be sure, and with that comes a great deal of time spent by clinicians to ensure the readings are accurately recorded.

And, without the benefit of a hands-on, face-to-face exam, many clinicians have also found it more difficult to assess and diagnosis their patients from afar—which only adds to the already time-consuming task of out-of-office visits.

So, while there is certainly a set of convenient perks that comes along with telemedicine (ie.: reduced exposure to pathogens, decreased practice overhead costs and a reduced amount of patient no-shows, just to name a few), the ever-present demands of documentation are no less burdensome than a typical in-office visit.

At the end of the day, though, the truth of the matter is that telemedicine giving patients greater access to clinicians—and keeping everyone safer and healthier. Although its recent proliferation was caused by a pandemic, chances are that telemedicine will become an ever-more common part of healthcare in the future.


Physicians Angels is the industry’s first Virtual Scribe company, providing real-time documentation directly into the physician’s EMR, along with Virtual Back Office services. Our services save the physician an average of 10 hours per week, thereby improving patient throughput and contributing to a better work/life balance for the physician and office staff. To learn more, visit physiciansangels.com or contact us.

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Physicians Angels

More time for physicians to see more patients, provide better care, and live their lives. Physicians Angels provides one-of-a-kind EMR data management services to healthcare providers through our real time Virtual Scribe service.