Documentation during videoconference

  • Videoconsultation

There are quite a few challenges when it comes to online medical consultation. One of them is the consistent documentation of the patient's history, particularly allergies and drug intolerances, and an objective evaluation and accurate documentation of the patient's current complaints and clinical symptoms.


Documenting patient's history

To make the right diagnosis, health care providers require information on preconditions, risk factors, and lifestyle, e.g., smoking, exercising, diet, etc.

To avoid mistakes while prescribing drugs and ointments, doctors need information on patient's allergies and intolerances. Drugs prescribed by other specialists and taken regularly must be taken into consideration for possible interactions.

Please ask your patient to provide information on the following topics, if not yet recorded.

- Actual drug list

- Allergies and intolerances

- Lifestyle habits – smoking, exercising, diet. (It might also be useful to ask about the actual weight and height.)

- Past hospital visits

- Minor and major surgical procedures

Many software providers for video consultations also provide digital forms that patients can fill in before their appointment. However, it might help build a reliable, professional relation if patients have sufficient time to tell their story.


Documenting symptoms and complaints

When it comes to rashes, skin pathologies, wound check-ups, experienced doctors can use pictures and video cameras to come to the right diagnosis. These pictures and screenshots can also be easily used for documentation purposes.

Functional impairments might be more difficult to document. For example, it is easy to identify a lack of elbow extension but how to document it properly if the goniometer cannot be applied?

Making a rough estimation based on the specialist's experience is the most common way out of this predicament.

However, advanced software solutions might help here sooner or later.


Although video consultations offer flexibility, they are not time-saving for health care professionals. Teleconsultations take approximately the same time as in-person-visits. They must be prepared and scheduled in advance, and finally, they require the same accurate documentation like regular consultations.


Telehealth and Telemedicine Books

  • Resources

“Telemedicine and Telehealth 2.0 A practical Guide for Medical Providers and Patients” by Victor Lyuboslavsky

Victor Lyuboslavsky is the Chief Technology Officer at - one of the leading telemedicine providers. Victor is recognized as one of the leading authorities on telemedicine technologies. His book provides an easy-to-read overview on telehealth.



“Telemedicine. A practical guide for professionals.” by Andrea Kamenca. A short guide which addresses some of the key aspects of telemedicine.




“Telehealth for Professionals. What do you need to know before logging on.” By Maryellen Evers. A 68p. strong brochure written from the prospective of a psychotherapist. It provides a brief overview over the clinical, ethical and legal aspects of video consultations. The book is inexpensive, easy-to-read, and the readers will find a draft for an informed consent and emergency attached.


Web-based sources

  • Resources


ATA is an organization focused on accelerating the adoption of telehealth. It represents a broad and inclusive member network of technology solution providers and payers, as well as partner organizations and alliances.

The ATA provides many useful resources on its website available to members and non-members alike. There is information on upcoming and recent webinars, practice guidelines and other resources (including the reviews of white papers and other research).


Practice Guidelines

This website offers a practice guideline archive from eye-care to teledermatology and telepathology.


ECHO Project

Project ECHO reduces health disparities in under-served and remote areas of the state, nation, and world through telementoring. The ECHO model uses videoconference technology and enabling software to connect providers in underserved communities (“spokes”) with teams of specialists and experts at regional, national, and global centers (the “hub”) for long-term telementoring, collaboration, and case-based learning on urgent social topics and conditions.



The National Consortium of Telehealth Resource Centers (NCTRC) is a collaborative of 12 regional and 2 national Telehealth Resource Centers (TRCs), committed to implementing telehealth programs. It is funded by the U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) and provides timely and accurate information on telehealth. Its goal is to help organizations and practices overcome barriers, advance telehealth education, and provide resources.



TBHI was envisioned, funded and nurtured by Dr. Marlene Maheu. TBHI offers professional training programs focused on the use of videoconferencing, the telephone, email, text messaging for various groups of health care professionals.

TBHI also offers staffing and consultation services to groups or individuals to develop telehealth competencies, follow evidence-based telehealth protocols and efficiently start service delivery/reimbursement.

Finding the right Term

No doubt, the healthcare has changed enormously in the last months leading to the almost inflationary use of terms like telemedicine, virtual care or telehealth. They all sound similar but what do they actually mean?Telemedicine, a term already used in the 1970s, stands literally for “healing at a distance” and signifies the use of technology (i.e. phones) to improve patients’ health outcomes by increasing access to care and information.[1]

Whereas, virtual care is widely used as a broad term which refers to telemedicine in terms of “healing at a distance” but is much broader and covers a variety of digital healthcare services.

However, the American Telehealth Association, founded in 1993, endorses the term telehealth on their website (also in incorporated in the name of the organization) by claiming that what was, beforehand, called telemedicine includes now a much broader array of services and technologies – AI, virtual reality and behavioral economic, just to name a few examples.[2]

But what is a TELEMEDICAL?

It is time to define new term. Thinking of pharmaceuticals which help patients to deal with a variety of symptoms. A Telemedical in this context is a digital tool, which as a pharmaceutical cannot be prescribed but, which helps patients to connect to their health professionals, to learn about their disease management, to access their data (images, reports etc.) and to avoid unnecessary hospital treatment through remote monitoring devices[3].  







[1] Strehle EM, Shabde N. One hundred years of telemedicine: does this new technology have a place in paediatrics? Archives of Disease in Childhood, 2006, 91(12):956–959.