Augmedix and Telemedicine

Telemedicine > Telemedicine Documentation Best Practice

Augmedix and Telemedicine

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Documentation Best Practices

Overview

Augmedix has developed best practices to help our clinicians and their documentation assistant navigate telemedicine visits easily and efficiently. 

Our highly trained assistants support clinicians managing patients via telemedicine exclusively, as well as clinicians providing both in-person and remote services to their patients. 

Compatible with any telemedicine platform, our best practices ensure streamlined workflows and up-to-date documentation requirements, which are integrated into both our Augmedix Live and Augmedix Notes products.

Augmedix Telemedicine User Engagement

  • Augmedix users represent 45 medical specialities
  • Approximately 90% of Augmedix users are conducting televisits
  • Augmedix users utilize multiple platforms to conduct televisits
  • Televisits are being conducted from varying locations (clinics, field clinics, clinician's homes, etc.)

Documentation Best Practices

Augmedix assistants are trained in the specific requirements needed to appropriately document telemedicine visits. 

It is critical to ensure that Augmedix has access to any telemedicine visit types/templates in your EHR. 

Documentation for telemedicine visits should contain the following to be appropriately billed:

1

Statement that the clinician received patient verbal consent to proceed with the visit.

2

Statement indicating the type of technology used (telephone or telemedicine platform)

   a) Indicate the specific technology (Zoom, Skype, patient portal, etc.)

3

Either date of last appointment if a previously managed problem(s) is being addressed, or a statement that the problem has not been previously managed.

4

Chief complaint.

5

History.

6

Physical exam (if relevant).

7

Assessment and plan.

8

Total time of the visit with the patient.

9

Statement indicating if the virtual visit resulted in an in-person appointment at the time the call ended.

Accepted Documentation Phrasing

Documentation Requirement

Suggested Phrasing

Informed consent: Patient consent for remote service

Verbal consent was obtained from the patient to conduct a (telephone visit/video visit via [name of telemedicine platform].

Patient consent for Augmedix/visit conducted via telehealth

Verbal consent was obtained from the patient to conduct a video visit via Zoom.

Indication of whether visit is a follow-up or new issue

Last appointment for this condition: [date/time] OR This patient has never been seen for this condition.

Visit duration

I spent XX minutes on [type of telemedicine platform] managing this patient.

Example: “I spent 8 minutes on the telephone managing this patient.”

Whether face-to-face follow-up planned

The call did/did not result in a face-to-face appointment at the time the call ended.