•  Clinical Documentation
•  Jeffrey Bennett, M.D.

Clinical Documentation of a Telepsychiatry Encounter is as important as with any clinical encounter but there may be some important additional considerations including a special need for:

• Documentation of the time, date, remote site location
• Documentation of the duration of the encounter and time spent face-to-face with the patient in interview and examination
• Documentation of the originating site location and personnel

Components of a clinical encounter which should be documented include:

• Chief Complaint or Reason for Encounter
• Referral Source
• History of Present Illness
• Current Treatments including medications and ongoing therapies
• Mental Status Examination
• Diagnoses
• Treatment Plan including

Inclusion of other items is sometimes needed such as:

• Past Medical, Family, Social Histories
• Review of Systems