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Telemedicine Documentation Risk – SOAP Note

I’ve been doing telemedicine since 2015, and the risk of poor telemedicine documentation seems greater with virtual medicine than brick and mortar. 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 reimburse companies for this service, a full SOAP note is required.

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

A 4-Line SOAP Note

A sample SOAP note I came across had all but 4 lines – I had to take a screenshot, but of course, I can’t share that here. It was written by another provider, and I saw the patient virtually for follow-up.

4 lines of notes won’t stand up in court and signals to any auditor that you don’t take patient care seriously. You obviously do, so proper telemedicine documentation is important to mitigate risk.

This is what 75% of the telemedicine SOAP notes look like, which I come across. Just because certain direct-to-consumer companies let clinicians get away with it doesn’t mean it’s good practice.

This is what lawyers are looking for, and there is no reason for a competent physician to write a note which can’t stand up in court.

In fact, it’ll take less time to dictate a longer note than it took for you to peck those 4 lines 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 counterproductive, but it is what it is. I hope this will change in the future as we set the standards of care based on the clinical setting.

Look at the wording from the Oregon Medical Board regarding telemedicine standards – it’s fairly clear. The SOAP note has to stand up to a note written by a clinician seeing a patient in the office.

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

The SOAP notes I write for my private virtual practice follow my strict guidelines. It’s not that I spend more time writing my notes, it’s that I write what is necessary to protect me.

Document More, Not Less

The above sample note I’m talking about has 17 words which I’m sure still took about 2 minutes to type. Or maybe it was cut and pasted 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. Attorneys love to dig through your old notes and past visits to hit you with accusations.

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 just a way for doctors to make money.

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: The patient has been having worsening sinus congestion and fevers for the past 14 days. They deny any shortness of breath. They have been having a cough as well with no shortness of breath. They have tried over the counter medication such as NyQuil and ibuprofen with minimal relief and no side effects.

O: They deny any tenderness over the lymph nodes of the neck. They deny any white spots on the tonsils. There is no rash on the face. They deny neck stiffness with movement. Mood and behavior seem appropriate.

A: This presentation is consistent with Acute sinusitis of bacterial etiology. The differential diagnosis includes viral sinusitis or Upper Respiratory Tract infection or allergic rhinitis.

P: Based on symptoms I suspect acute bacterial sinusitis. Based on 2 weeks of symptoms and worsening will recommend a course of Augmentin 875 mg twice daily for 10 days. The patient should follow up with their own PCP after treatment. Return precautions were reviewed. Alternative management options were discussed. Medication side effects were also discussed. The patient is to follow-up with PCP immediately if symptoms worsen. The paatient agrees with management.

Using Dictation to Speed up the SOPA Note Process

But who 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.

My workflow is to open a Chrome Doc tab, and I just start dictating. When I did this sample documentation for this post, I only had 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.

SOAP Note Anatomy for Good Telemedicine Documentation

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, we would write HEADSS assessments and write far lengthier progress notes.

We write notes to cover ourselves and please regulators. So here are the factors of a good telemedicine SOAP note.

1. 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.

Whenever possible, write in full sentences. Because you are dictating, you can be as verbose as you like. Any errors in the note can be caught with your Grammarly extension.

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 the 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, write that. If they say they told you on the phone that their daughter had a 103 fever and you didn’t write anything, then you’re in trouble.

2. Objective

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

  • the patient is speaking in 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 you in court, the fact that you put in the effort will matter:

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

3. Assessment

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

The assessment aims to figure out what the clinician was thinking during and after the patient visit. If you didn’t document it, then you didn’t consider it.

In the assessment, I would explain why you think it’s not appendicitis or ovarian torsion. And why you don’t think the patient has bacterial pneumonia, or why is it not meningitis.

This is especially important when the patient could potentially have such things. After all, if you can’t properly triage a patient in a telemedicine visit, you are considered incompetent.

“I 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.

The only time you should write a symptom code as your diagnosis is if you are unsure or have a working diagnosis. The differential diagnosis should point that out really clearly.

4. Plan

Here are the points I would recommend that you cover in the plan section, which should lay out what you’re planning on doing and what the patient should do after the visit with you.

In your SOAP note telemedicine documentation, you want to discharge and dispo the patient appropriately. It’s wordy, yes, but remember, you have the power of dictation technology.

  1. further explanation of the assessment if it’s relevant
  2. your differential diagnosis if you don’t put it in the assessment
  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 symptoms

“I Cannot refill blood pressure medications because the patient hasn’t had a recent K or Cr. But there is no imminent risk at this time.”

“The patient was upset with my diagnosis of a viral etiology and didn’t agree with my treatment plan. She insisted on antibiotics. I suggested she follow up with her PCP for a physical exam and a second opinion.”

“We discussed what to look for in case their symptoms worsen, and we discussed going to the ER/UC in such a case.” 

Telemedicine Company Expectations

Many physicians believe that they will get into trouble if they don’t prescribe medications on a telemedicine visit.

This isn’t true.

What is true is that many telemedicine companies are aiming for high customer satisfaction scores, of course. But if you can justify your reason for not prescribing it nobody will come after you.

The progress note, again, is what it comes down to.

If you don’t know how to say no without coming across as dismissive, I recommend doing further reading on bedside manner. Or, really, we should call it customer service.

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 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.”

The Difficult Cases

A persistent mom who calls about her child, who she is convinced has an ear infection and for which she demands antibiotics … sorry, I’m not going to let an upset mom put my medical license at risk.

“I am not able to look inside the ear and even though you are telling me that this always ends up being a bacterial infection it’s not the way we diagnose this condition and it would be unfair to your child and unethical for me to prescribe something without a proper examination.”

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 appreciate any advice I have, and I don’t always send them to the doctor. Watchful waiting is perfectly appropriate.

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

26 replies on “Telemedicine Documentation Risk – SOAP Note”

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.

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?

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

-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

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

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?

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

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.

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.

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?

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.

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.

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!

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.

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

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.

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?

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.

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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