Telemedicine

visit conducted with use of interactive audio and/or video telecommunications system that permits real-time patient-provider communication. patient identity/location verified and informed consent obtained by staff. patient advised of potential risks and limitations of telemedicine
[checkbox name="historian" value="new patient|existing patient||history provided by patient|history provided by family member||SO/family member present during visit|chaperon/MA present during visit||interpretation provided by family member/SO|interpretation provided by MA|"][textarea cols=50 rows=3]
[checkbox memo="EXAM LIMITED" name="lim" value=""][conditional field="lim" condition="(lim).is('')"]EXAME LIMITED due to: [checkbox name="exlim" value="language barrier|pain|cognition|affect|hearing impairment|poor connection|poor effort/cooperation|"][textarea cols=50 rows=3][/conditional]
HPI/SYMPTOMS: [checkbox name="hpi" value="new problem|chronic condition|acute exacerbation of chronic condition|follow up laboratory/diagnostic studies||started today|started yesterday|started several days ago|started more than 1 week ago|started months ago|started years ago|unsure||still present|increasing in severity|persisting|occasional|decreasing|resolved||affected by medication|affected by exertion|affected by pressure|affected by position/movement|affected by rest|affected by weather|worse at night||as in cc|"][textarea cols=50 rows=3]

[checkbox memo="MEDICATIONS" name="med" value=""][conditional field="med" condition="(med).is('')"]MEDICATIONS: allergies reviewed, [checkbox name="medications" value="taking OTC|taking RX||reports no side effects|reports side effects||effective|partially effective|not effective||demonstrates knowledge of medications/reasons/dosages|unable to name medications/reasons/dosages||medication list/labels/containers available for review|medication list/labels/containers not available for review||insulin/BS log available for review|insulin/BS log not available for review||none reported|"][textarea cols=50 rows=3][/conditional]

PERTINENT MEDICAL HISTORY: [checkbox name="recent" value="ER/UC visit|hospitalization/surgery/procedure|specialty consult|new/changed medications||travel|sick contact|c19 positive test|c19 infection|c19 immunization started|c19 immunization competed||non-contributory||none provided|"][textarea cols=50 rows=3]

[checkbox memo="prevent" name="prevent" value=""][conditional field="prevent" condition="(prevent).is('')"]PREVENTIVE: [checkbox name="annual" value="annual dilated eye exam|annual diabetic foot exam|annual microalbumin||fecal blood Q1|colonoscopy Q10||DEXA|LDCT|AAA Doppler||PAP|mammogram||PSA|DRE||flu|pneumo|DT|shingles||referred to local pharmacy to verify vaccination status and administer vaccines, if indicated|"][textarea cols=50 rows=3][/conditional]

REVIEW OF SYSTEMS: negative except as stated in HPI
General:[textarea name="variable_5" default=" does not report fever, chills, fatigue, malaise, or weight changes"]
HEENT:[textarea name="variable_6" default=" does not report headaches, vision changes, eye redness/discharge, pain with EOM, facial swelling, earache, ringing, ear discharge, nasal congestion, rhinorrhea, mouth sores, changes in taste, sore throat, neck swelling"]
CV:[textarea name="variable_7" default=" does not report chest pain, SOB, palpitations, fainting, or ankle swelling"]
Pulmonary:[textarea name="variable_8" default=" does not report shortness of breath, cough, wheezing, or chest wall pain with breathing"]
GI:[textarea name="variable_9" default=" does not report poor appetite, nausea, vomiting, abdominal pain, constipation, or diarrhea"]
GU:[textarea name="variable_10" default=" does not report dysuria, hematuria, frequency, discharge, or bleeding"]
MSK:[textarea name="variable_11" default=" does not report myalgias, arthralgias, localized muscle/soft tissues pain/swelling, or joint pain/swelling"]
Neurologic:[textarea name="variable_13" default=" does not report dizziness, seizures, tremor, balance problems, weakness, or falls"]
Psychiatric:[textarea name="variable_14" default=" does not report depression, anxiety, mood swings, memory loss, or insomnia"]
Dermatologic:[textarea name="variable_12" default=" does not report rashes, redness, pruritus, hair loss, swelling, or wounds"]
Endocrine:[textarea name="variable_15" default=" does not report polyphagia, polydipsia, night sweats, hot flashes, or heat/cold intolerance"]
Hematologic/lymphatic:[textarea name="variable_16" default=" does not report abnormal bleeding/bruising"]

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[checkbox memo="OUTSIDE DIAGNOSTIC AND LABORATORY" name="outside_diag" value=""][conditional field="outside_diag" condition="(outside_diag).is('')"]OUTSIDE DIAGNOSTICS: [checkbox name="labs_imaging" value="normal|abnormal|non-specific findings|no acute findings||results reviewed/discussed with pt/family|"][textarea cols=50 rows=3][/conditional]

[checkbox memo="SPECIALTY CONSULTATIONS" name="specialty" value=""][conditional field="specialty" condition="(specialty).is('')"]SPECIALTY CONSULTATIONS: [checkbox name="spec" value="normal|abnormal|non-specific findings|no acute findings||results reviewed/discussed with pt/family|"][textarea cols=50 rows=3][/conditional]

General: [checkbox name="appearance" value="alert|well-appearing|non-toxic|normal WOB|no acute distress||malaised|short of breath|diaphoretic|coughing during exam|sniffling during exam||drowsy|appears impaired|slumped||unable to assess|"][textarea cols=50 rows=1]
HENT: [checkbox name="head" value="hearing grossly intact|speaks in clear and unmuffled voice|no stridor audible||normocephalic|symmetrical face|CN grossly intact|EOM intact without nystagmus|clear conjunctiva||reports no trouble smiling or chewing|reports no changes in vision or photophobia|reports no changes in hearing|no tragal tenderness with self-palpation|no mastoid tenderness with self-palpation|reports being able to use both nostrils|no tenderness with applying pressure to sinus areas||unable to assess|"][textarea cols=50 rows=1]
Chest/Lungs: [checkbox name="lungs" value="normal respiratory effort|no tachypnea|speaking in full sentences|no audible wheezing||symmetrical chest expansion||audible coughing||chest pain with self-palpation||reports respiratory distress|reports chest pain with breathing||unable to assess|"][textarea cols=50 rows=1]
Extremities: [checkbox name="ext" value="no No cyanosis, clubbing or edema||unable to assess|"][textarea cols=50 rows=1]
Neuro: [checkbox name="neuro" value="normal concentration and attention|memory grossly intact||no involuntary movements||tremor|tardive dyskinesia|tics||reports no changes in balance or coordination||unable to assess|"][textarea cols=50 rows=1]
Speech/Vocalization: [checkbox name="speech" value="normal for age|clear and  coherent||slurred|mumbling to self|monotonous|stuttering||hypoverbal|hyperverbal||loud|soft||slow|rapid|pressured||groaning|sighing|crying||perseveration|flight of ideas|repetitive questions||self-depreciating statements|repetitive statements of impending doom|repetitive non-health related/financial concerns||personal safety concerns|suicidal ideation/threats||insisting on particular medication, test, referral, or accommodation||raising voice|defensive|argumentative|cursing, swearing|previous providers/staff criticisms|verbal threats|sexual remarks|racist remarks||unable to assess|"][textarea cols=50 rows=1]
Behavior/Psychomotor Activity: [checkbox name="behavior" value="calm, pleasant, respectful|cooperative with history and exam||guarded|anxious|irritable|frustrated||labile|agitated|hostile|forceful||pacing|fidgeting|picking skin|twirling hair|cracking knuckles|grimacing, furrowing eyebrows|tightening jaw|breathing hard|intense staring|threatening gestures|fist-clenching||withdrawn|bradykinetic|indifferent|appears to be responding to internal psychotic process||unable to assess|"][textarea cols=50 rows=1]


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PLAN OF CARE: patient/family verbalized understanding of dx and POC, [checkbox name="discussed" value="agreed with dx and POC|did not agree with dx and POC, encouraged to seek second opinion|"][textarea cols=50 rows=3]
ORDERS - MA: [checkbox name="order_MA" value="injection|dsg|procedure||none|"][textarea cols=50 rows=3]
ORDERS - RX: [checkbox name="order_RX" value="OTC||electronic|paper|given to MA to be transmitted to pharmacy||none|"][textarea cols=50 rows=5]
ORDERS - LABS: [checkbox name="order_lab" value="CBC|CMP|TSH|A1C|Lipids|PSA|FOBT/FIT|UA||HIV, RPR, HCV, GC, CT|UDS||none|"][textarea cols=50 rows=3]
ORDERS - IMAGING: [checkbox name="order_imaging" value="X-ray|US|MRI||none|"][textarea cols=50 rows=3]
ORDERS - REFERRALS: [checkbox name="order_refer" value="local pharmacy to verify vaccination status and administer vaccines, if indicated||deferred||none|"][textarea cols=50 rows=3]
ORDERS - FORMS: [checkbox name="forms" value="excuse|accomodations|clearance|return to school/work|school/participation physical||none|"][textarea cols=50 rows=3]

[checkbox memo="COORDINATION OF CARE" name="coord" value=""][conditional field="coord" condition="(coord).is('')"]COORDINATION OF CARE: case reviewed by/discussed with attending[textarea cols=50 rows=3][/conditional]

REVIEWED/DISCUSSED/INSTRUCTED ON: exam findings, POC, risks of/benefits of/alternatives to proposed POC, compliance with treatment regimen, appropriate follow up specific to condition, indications for immediate direct evaluation and/or contacting emergency services, [checkbox name="instructions" value="previous visits|laboratory/diagnostic studies|specialty consults|hospital visits||medications|PMP|reporting medication side effects immediately|medication compliance|bringing all medications/labels to all visits||home BP checks|home BS checks|daily weights||controlling chronic conditions|age- and disease-appropriate screening and immunization||lifestyle modification, including: diet, avoiding/limiting alcohol, limiting sugar/carbs, limiting high fat intake, liming salt intake, staying active/daily physical activity/exercise, wt maintenance, stress reduction, sleep hygiene||alcohol cessation|smoking cessation||NSAIDs prn|cognitive restructuring in managing chronic conditions|symptom exacerbation through rebound mechanism|risks of respiratory depression with polypharmacy|"][textarea cols=50 rows=3]
DISCHARGE CONDITION/SAFETY: [checkbox name="discharge" value="improved|stable|unchanged||no safety concerns at this time||safety concerns d/t depressed agitated mood|safety concerns d/t impulsiveness|safety concerns d/t hostile temper|safety concerns d/t past attempts|safety concerns d/t current suicidal verbalization|"][textarea cols=50 rows=3]

DISPOSITION: [checkbox name="disposition" value="home||advised to use UC for acute non-emergent problems|ER for immediate treatment via 911|ER for immediate treatment via private transport||declined emergency transfer||left exam room before visit conclusion|was asked to leave clinic|"][textarea cols=50 rows=3]
FOLLOW UP: as discussed, sooner if condition worsens or new symptoms arise, contact 911/ER if significant increase in s/sx or appearance of new/danger s/sx, [checkbox name="next" value="here|in-person|televisit||24 hours|2-3 days|1-2 weeks|3 weeks||30 days|6 weeks|2-3 months|4-5 months|6 months|12 months||f/u acute episode|f/u labs|f/u imaging|f/u med change/new|"][textarea cols=50 rows=3]

BARRIERS TO CARE: [checkbox name="barriers" value="language barrier|socio-cultural factors||poor effort/cooperation with exam|incomplete history|history not supported by findings|vague complaints||supporting documentation unavailable|failed to obtain old records|failed to complete referrals or testing|| multiple comorbidities|polypharmacy|multiple providers/prescribers|intolerance of/allergty to/therapeutic failure on multiple meds||frequent ER/UC visits|frequent office contacts||poor compliance with POC|negative attitude to proposed tx|lack of interest in non-drug tx||overreliance on short-acting meds|overwhelming focus on Rx drugs||poor insight|lack of motivation|dependent attitude||preoccupation with illness|unhealthy coping mechanisms|somatization|catastrophization|pessimism|overgeneralization|unrealistic health beliefs||psych comorbidity|anxiety|depression|alcohol or substance use||social or occupational dysfunction|secondary gain||hostile/disruptive behavior|affect||inability to personally examine||none noted at this time|"][textarea cols=50 rows=1]