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Telemedicine SOAP Note Documentation Risk

I’ve been doing telemedicine for quite a few years and the risk of poor documentation is probably even greater with virtual medicine. I’ve seen a lot of poor telemedicine documentation by clinicians.

Telemedicine has been through various iterations and up until recently no physical exam was documented. Now that insurance companies and CMS are reimbursing companies for this service a full SOAP note is required.

As of recently, with the COVID-19 business, a lot of entities are offering waivers for HIPAA and state licensing and patient location. But that doesn’t mean you’ll be off the hook for documentation.

Sample SOAP Note

Here is a sample SOAP note I just came across after a patient called for a 2-day follow-up because she was getting worse. It was written by another provider and I saw the patient virtually for follow up.

This is what 90% of the telemedicine notes look like which I come across. And if your SOAP notes look like the example above then you are exposing yourself to major risk.

This is what lawyers are looking for and there is not reason for a competent physician to write such a note. In fact, it’ll take less time to dictate a longer note than it took for you to peck this on a keyboard.

Telemedicine Documentation Standards

You may not be aware but the state medical boards hold physicians who complete a telemedicine visit to the same standard as a physician who saw the patient in person.

Of course this is absolutely bullshit but it is what it is.

Look at the wording from the Oregon Medical Board regarding telemedicine standards:

If we are held to the standards as an in-office visit and we prescribe an antibiotic or refill a medicine, without a physical exam and without vitals, then we are in deep shit if something goes wrong.

A SOAP Note

What would make a clinician document less on a telemedicine soap note versus an in-person visit? You would think the telemedicine documentation would be stepped up.

My dear physician colleagues, if you’re going to be earning that fat telemedicine dollar please pay attention to the pitfalls of telemedicine.

Speaking of that, if you want to earn more money doing telemedicine then I highly recommend my Faster Telemedicine Course. It’s been selling like hotcakes ever since this viral outbreak and now that more physicians are turning towards telemedicine.

Document More, Not Less

The above sample note which I screenshot has 17 words which I’m sure still took about 60 seconds to type. Or maybe it was cut and paste which would be a huge disaster because should a case like that go to trial then you better believe that your other charts would be subpoenaed as well.

The main point I want to get across is that every lawyer and medical board investigator who is out to get you will lead with the assumption that telemedicine is bullshit. They will try to discredit the concept and make it seem as though you are negligent for even considering to treat a patient using telemedicine.

Proper SOAP Documentation

This might be a more effective way to write a SOAP note:


S: Patient has been having sinus congestion and fevers for the past 14 Days which are getting worse. Denies any shortness of breath. Has been having a cough as well. Has been trying over the counter medication such as NyQuil and ibuprofen.

O: He denies any tenderness over the lymph nodes. Denies any pus on the tonsils. Has no rash on the face. Denies neck stiffness. No redness over the face. Mood and behavior appropriate.

A: Acute sinusitis

P: Based on symptoms I suspect acute bacterial sinusitis. Differential diagnosis includes viral sinusitis versus allergic rhinitis vs URI. Based on 2 weeks of symptoms and worsening will recommend a course of Augmentin 875 mg twice daily for 10 days. Should f/u with PCP after treatment. Return precautions reviewed. Alternative management options discussed. Medication side effects discussed. Patient to follow-up with PCP symptoms worsen. Patient agrees with management.


But who the shit has the time to write this 143 word novel?!

It took me 50 seconds to get that note done and it was all dictated for free using Google Documents. I’ve written about this before so you can reference that post.

I have the other tab open in Google Chrome and it looks like the screenshot above. I just start dictating and when I did this sample documentation for this post I only had only 2 errors to correct – not bad.

I can go to court with the above but I wouldn’t feel comfortable going to court with the first anemic SOAP sample I shared with you guys.

Want to learn more? Check out my Telemedicine Course which goes through every aspect of being a great telemedicine clinicians. From prescribing less to increasing your volume to decreasing your risk.

SOAP Factors

Let’s face it. We don’t document our SOAP notes for the patient’s sake or for true continuity of care. If that was the case when we would be writing HEADSS assessments and writing far lengthier notes.

We write notes to cover ourselves. Yes, I know, defensive medicine doesn’t work. And yes, I know, if you’re really nice to a patient then they won’t sue you even if you cut off the wrong leg.

Subjective

Mention the context because it helps to be specific which makes your note stand out. If a person says that they were driving to Seattle right when they started feeling their fevers and chills come on then mention that.

The subjective is where you want your pertinent negatives:

  • no difficulty swallowing
  • no rash on the body
  • no SOB
  • no neck stiffness
  • no blood in the stool
  • no blood in phlegm

Include what the patient has already taken as far as OTC meds. No need to mention prescription meds if they entered it into the telemedicine software and you reviewed it. But quite commonly patients won’t enter it or will leave out serious meds such as coumadin.

Mention medical problems if they weren’t entered by the patient or enter “patient has no other medical conditions and isn’t taking any other medications at this time”.

If a parent reports their child had a 100.1 fever then write that. Should they go back and say that they told you on the phone that their daughter had a 103 fever and you didn’t write anything then you’re screwed.

Objective

You may not be there to do an exam on the patient but you can definitely write the following:

  • patient is speaking full sentences
  • mood and behavior appropriate
  • no signs of distress
  • no wheezing heard
  • audible congestion in his voice
  • coughing on the phone

You can take it a step further and though this may not save yourself in court, the fact that you put in the effort will matter:

  • patient doesn’t see pus on the tonsils
  • he cannot feel any enlarged cervical lymph nodes
  • can move neck in all directions without pain
  • able to walk normally
  • able to move all extremities without weakness
  • reports facial muscles look symmetrical
  • patient has no tenderness over the abdomen with pressure
  • no CVA tenderness according to patient

Assessment

I write what I think the diagnosis is if it’s obvious otherwise I provide a short explanation for my telemedicine documentation.

“Cannot rule out Kawasaki’s though most likely this is a URI or measles”

Don’t write a symptom such as fever or cough in your assessment – that looks weak which means it’ll be tough to defend in court.

Plan

Here are the points I would recommend that you cover:

  1. what you think it is if you didn’t address it in the assessment
  2. your differential diagnosis
  3. why you don’t think it’s a red flag diagnosis
  4. the options you offered the patient for management
  5. the medication and directions you ordered
  6. that you discussed the medication side effects
  7. that the patient agreed or didn’t agree with your plan
  8. your follow-up plan for the patient
  9. precautions for worsening of symptoms

“Cannot refill blood pressure medications because patient hasn’t had a recent K or Cr.”

“Patient was upset with my diagnosis of a viral etiology and didn’t agree with my treatment plan. She insisted on antibiotics. Suggested she follow-up with her PCP.”

“We discussed what to look for in case symptoms worsen in which case patient to go to ER/UC.” 

Telemedicine Company Expectations

For those who are doing telemedicine work and worried that if they practice conservatively and avoid prescribing medications then they will get shit from the telemedicine company, that’s absolutely and 100% not true.

For example, I’ll never give a macrolide for a possible PNA with a telephone visit – no way. That’s suicide because if the patient becomes septic or ends up having had a PE then I won’t have a leg to stand on.

“Dr. Mo, please tell the jury why you didn’t get a pulse ox or respiratory rate on this patient with SOB to rule out a PE. And also tell them how you diagnosed a PNA without a CXR.”

A pushy mom who calls about her child who she is convinced has an ear infection and for which she demands antibiotics … fuck ’em. Sorry, I know that’s mean but I’m not going to let some pissy mom put my medical license at risk.

I’m being a little harsh intentionally to get the point across. In fact, whenever I explain to the parent that I cannot diagnose an ear infection without visualizing the ear they are very appreciative of any advice I have and I don’t always send them into the doctor. Watchful waiting is perfectly appropriate.

I have seen a lot of patients for a lot of different telemedicine companies and not a single one has given me shit for sending a patient into the office for a face-to-face evaluation. Or for denying someone refill of their ACE-I because they didn’t have recent blood work.

26 Comments

  1. Sharon B Anderson

    Hilarious and true!

  2. Tammy D'Souza

    I am a Family Medicine doc going to start Telemed services for the hospital I work for in two months and trying to find resources — Can you please suggest where I should begin this search. Are there docs who would be willing to share their expertise.

  3. I have been sharing a ton of resources on this website. A search for telemedicine on this site should provide a lot. What are you looking for specifically?

  4. Lindsey Langmaid

    Nice! Where is the time spent documented ? Codes are based on time so you might want to update your cool tool. It’s always overlooked even for smoking cessation and other time based therapies.

    Thanks for the encouraging words and reminders1

  5. Anonymous

    Awesome thanks for sharing

  6. I need help understanding billing during this covid 19 situation can you help me?

  7. -no cost-sharing for covid testing
    -cost sharing can be waived (copays and deductible) for medicare when telehealth services are provided
    -regular phone calls (99441-99443) are not reimbursed by CMS
    -services must be offered by a clinician (not RN)
    -no geographic restriction for patients, they can call from anywhere
    -any form of communication can be used/HIPAA restrictions waived
    -G2012 used for checking in on a patient (a visit initiated by the clinic)
    -99421/99422/99423 are patient initiated visits
    -99453/99454/99457 used for remote monitoring of physiologic data (pulse, rep rate, temp, etc)
    -J12.89 (other viral pneumonia Dx)
    -J20.8 (acute bronchitis due to other specified organisms Dx)
    -J80 (acute respiratory distress syndrome Dx)
    -J98.8 (other specified respiratory disorders Dx)
    -Z03.818 (encounter for observation for suspected exposure Dx)
    -Z20.828 (contact with and suspected exposure to other viral communicable diseases Dx)
    -R05 (cough), R06.02 (shortness of breath), or R50.9 (fever, unspecified)
    -do not use B34.2 (coronavirus infection, unspecified)
    -Apple FaceTime, Facebook Messenger video chat, Google Hangouts video, Skype are okay to use for telemedicine visit

  8. Anonymous

    Can you do a pe or Medicare wellness visit with a video visit. What do you document in objective? Will insurance cover

  9. Yes, you can do an annual wellness visit with medicare. Refer to the other posts on this website regarding medicare telemedicine resources. Which insurance are you referring to?

  10. Anonymous

    I need help to understand the E/M coding for telemedicine visits …. does it have to be time based or can we still follow 2 out of 3 criterias of documentation for CPT coding.. please help.
    Thanks

  11. Depend on which E/M codes you’re using, most will be time based. Please refer to my previous comments and posts regarding coding for telemedicine.

  12. Is the physical exam I can obtain over a telemedicine visit enough to bill a new patient code (99202) in my PCP office?

  13. Yes, the physical exam is enough for a new patient visit – not sure that’s the right code you’re using, I posted something somewhere on all the codes.

  14. Lisa

    What verbiage should the provider use if the telemedicine visit was performed in his/her home vs the office. Does the provider have to state where he is during the televisit or just the patient?

  15. Depends on your state’s regulation. The location of the provider isn’t asked in any state as far as I’m aware.

  16. Diana

    If a video-audio communication was started but the microphone had issues on the patient’s side and the doc had to call the patient on the phone to perform the exam. How should this be documented and billed ( telehealth visit (99212 or Phone E/M – 99442)? Appreciate your comments.

  17. It’s always a telehealth visit if your communication was performed through a HIPAA compliant method. If it failed and you had a use a backup method, that doesn’t negate your AV capabilities.

  18. Kristen

    In telehealth charting (with all of the waivers and what not included) – are vital recordings required to bill for an E&M? Can you point me to any true documentation that states they are or are not required? Obviously, most patients can check temp – provide weight and height (which can calculate BMI) – but what about HR? RR? etc… would love your input!

  19. No, vitals aren’t necessary, they are part of the physical exam.
    I have listed lots of sources on this site, a search might uncover them.

  20. Gary Kulka

    Telephone Services are now billable:

    A 5-30 minute evaluation and management service with an established patient via telephone. Not reimbursable if a related evaluation and management service was provided during the previous 7 days or if the service leads to or results in an evaluation and management service within 24 hours or soonest available appointment.
    Use CPT codes 99441 – 99443

  21. Elizabeth Adams

    Hello

    Is there any difference in reimbursement for capitated patients?

  22. Each capitation contract is unique and so a blanket answer won’t suffice. If you’re referring to telemedicine then it would depend on your state. However, fair to say that most insurers will likely treat an in-person visit the same as a virtual visit, meaning that there won’t be a reimbursement difference.

  23. Maryland NP

    I am glad I found this post. I am a nurse practitioner practicing telemedicine in Maryland with an app called PUSH. I know my documentation needs a lot of improvement. PUSH app does not use ICD 10 codes. It is fee for service only, you choose your fee. It does not do controlled substances, but you can do lifestyle medications (Addyi, ED meds, Latisse, etc) if you so choose. After reading the above I plan to do many improvements in my documentation. Have you reviewed PUSH Health?

  24. I haven’t heard of PUSH but am familiar with many such telemedicine services. Your documentation is critical because many such companies are comfortable throwing you under the bus and many don’t follow all of the telemedicine rules. THey are only offering you a place to perform telemedicine – and since they are just providing the platform, they aren’t liable, we are. I think it’s easier to get into trouble prescribing such lifestyle meds … you would think patients would be more grateful because these services are available, but I think there is more risk with such things.

  25. Anonymous

    Where do I find a basic template on what to document as a beginner?

  26. This post should have laid everything out for you. As for beginner, not sure what you mean. If you mean new to telemedicine then you should probably take a course to learn how to handle a telemedicine visit. Most of your telemedicine companies should offer you a good intro to that.

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