Electronic Medical Records and Documentation in Telemedicine

As with any physician-patient encounter, telemedicine needs to include proper documentation and use of electronic medical records. In Part V of our series, Physician Focus: Telemedicine, we talk with Dr. Jonathan Terry, an award-winning osteopathic physician and surgeon and psychiatrist who uses telemedicine extensively in his practice. Dr. Terry explains that, in addition to documenting all of the usual aspects of the provider-patient encounter, physicians and practices using telemedicine should document that the patient was seen using telemedicine and why telemedicine was used. Also, when using ICD-10 diagnoses and CPT codes to fully document all aspects of the encounter, including the physical locations of the provider and patient during the encounter.

Telemedicine can act as a ‘shortcut’ in many ways, allowing physicians and patients to interact in ways that have not been possible in the past. However, physicians cannot take shortcuts when it comes to documentation and electronic medical records. If anything, physicians should be even more aware of these procedures when using new and less common technologies. To learn more, watch Part V of our series below. To watch the full interview, click here.