Is there additional language that I should include in my medical record documentation when offering care by telehealth during this time?

We (and a cross section of our outside defense counsel) strongly recommend practices incorporate the following language into any applicable notes by copy and paste:

On March 11, 2020, the World Health Organization declared the COVID-19 (Novel Coronavirus) viral disease to be a pandemic. As a result of this emergency, a rapidly evolving situation, practice patterns for physicians, physician assistants, and nurse practitioners are shifting to accommodate the need to treat in conjunction with unprecedented guidance from federal, state, and local authorities—which include, but are not limited to, self-quarantines and/or limiting physical proximity to others under any number of circumstances.

It is within this context (and with the understanding that this method of patient encounter is in the patient’s best interest as well as the health and safety of other patients and the public) that “telehealth” is being provided for this patient encounter rather than a face-to-face visit.

This patient encounter is appropriate and reasonable under the circumstances given the patient’s particular presentation at this time. The patient has been advised of the potential risks and limitations of this mode of treatment (including, but not limited to, the absence of in-person examination) and has agreed to be treated in a remote fashion in spite of them.

Any and all of the patient’s/patient’s family’s questions on this issue have been answered, and I have made no promises or guarantees to the patient. The patient has also been advised to contact this office for worsening conditions or problems, and seek emergency medical treatment and/or call 911 if the patient deems either necessary.”

News & Knowledge
All Curi recommendations are based on current CDC criteria at the time of publication. CDC guidance for SARS-CoV-2 infection may, or may not, be adopted by state and local health departments to respond to rapidly changing local circumstances. Providers should always check with their local health department to see if the CDC’s guidance on any given topic has been modified (particularly if more restrictive) from the CDC’s recommended guidelines. Follow this link https://www.cdc.gov/publichealthgateway/healthdirectories/index.html for contact information to your state/local health department. If local recommendations vary from those of the CDC, and you are unsure what recommendations to follow, then it is safer to follow the more restrictive guidelines/recommendations.