Virtually Easy Documentation… Sort of…

Ah, documentation! Every physician loves this. Really!


Okay, when you first see a patient, you will curse the doc before you who didn’t document thoroughly enough. We’ve all been there. We know how important it is. But nobody likes doing the actual documentation. All of those pesky requirements… Meaningful use, H&P versus consults, New versus Established, 14-system reviews… And don’t forget all of your attestations! Heck, my wound care coder even asked if I would include a glossary of acronyms attached to each of my patient notes so her team wouldn’t have to keep looking things up. By the time you pack it all in, there’s about 83% clinical fluff, 12% good stuff and 5% system disclaimers appended to the bottom.

Unfortunately, I can’t change that in this article. But as we have been talking about how telehealth relates to our traditional face-to-face experience, I thought I would mention a few things that I’ve dug up on my archaeological expedition in the ancient halls of medical documentation.

There is some good news! Our existing method of documentation still works! I know!! It’s unbelievable! You mean that I don’t have to learn an entirely new system in order to get this done? It’s a first in the history of medicine! At least since the introduction of the EHR, right?

Indeed. The regular H&P formats for New and Established patients are still perfectly fine. There are, however, a few new changes. Nothing terrible, but be mindful — If you forget to do them, your auditor may make you pay for your sins…


  • History of Present Illness — You still need to describe what’s going on.
  • Past Medical History — You still need to mention what’s already happened.
  • Family History — Yep. They still want you to spell it out.
  • Social History — The good, the bad and the durations…
  • Review of Systems — However many points you need to address, particularly in a New patient, be sure to put them in!
  • Physical Exam — Umm, we’ll get to that one…
  • Results — Labs, radiology, pathology… Whatever you need to include here still needs to be inserted.
  • Assessment — Don’t forget to click on your ICD-10 codes!
  • Plan — Ah, the best part! Always a great place to start when you want to figure out where you left off with your patient discussion last time.
  • Attestation — If you are like a lot of docs, you may have to include an attestation at the end of your notes. Often this relates to time-based billing. You may have additional attestations if you are supervising a resident or an advanced practice provider [APP]. Be sure to include whatever applies here!


  • Physical Exam — As you can’t actually do a physical exam on a virtual patient, what should you do here? There are many opinions, but I would suggest that if you take a patient’s word on something, make sure you state clearly that this finding is “patient-reported” or something to that effect. For example, if a patient is able to take her own vitals, you could certainly include that in your note. In fact, it’s probably a pretty good idea in most cases! But it is important to note this so that you [or whoever follows you] understands that there may be some variability in this data quality. Capturing photos and images to insert into your PE section is a reasonable thing to do, but I cannot find any rule at this point that requires this. Please note that as CMS is rapidly revising telehealth rules, this may changes. From my standpoint, I plan to add photo documentation whenever I can. For some problems, such as an ulcer, wound photos and measurements are often required by payors. Be sure to check for these little sidebar rules if you feel they apply to your specific practice.
  • Virtual Encounter Attestation — In addition to all of the extra stuff they require of you already, you also must include a second attestation with each of your virtual visit notes that specifically state that this was a telemedicine encounter. Pre-COVID, you were also required to document the state you were in [geographically, not psychologically… That’s a whole other discussion] as well as the state your patient was in at the time of your visit. This was originally intended to prevent licensing issues; however, the COVID changes have lifted many of these restrictions. Look for further news on this front as things settle down.

Now, you need to take all of this with a grain of salt. CMS is planning some big changes over the next year in this whole process. With the current health crisis, it remains to be seen how this will be affected. In the meantime, however, sit tight. Keep doing what you’re doing. And when you try some virtual visits with your patients to keep the care flow going, keep these points in mind. If you use a template in your EHR, be sure to edit the Physical Exam as well as any other pertinent sections so they accurately reflect what you did in your telehealth encounter! I’m sure you have seen the occasional faux pas in a note where the post-amputation patient is documented as having palpable foot pulses. Don’t be that guy.


Just a few references regarding CMS H&P documentation in case you needed a refresher…

CMS Complying with Medical Records Requirements

CMS Telemedicine Health Care Provider Fact Sheet

MGMA Resources — Navigating Telehealth Billing Requirements

Well! Hopefully, these last few posts have been at least a little be helpful in demystifying this telehealth process. Please get in touch if you have additional resources, comments or experience!

Until then…


Photo Credit: Ag Ku from Pixabay

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