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Clinical Documentation

  • 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

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