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.