I’ve been asked about the physical exam portion of a telemedicine visit a lot. So here is a physical exam template that you can use in order to document a physical exam on a telemedicine visit.
Subjective Physical Exam
Understand that the physical exam normally falls under the objective part of the SOAP note. But during a telemedicine visit you would create a mostly subjective physical exam template.
There are some objective findings you can determine by looking at the video or even listening in on the telephone call. Though probably not much you can get from a text interaction.
You will never touch the patient. Obvy, I know, but it’s easy to get lost in the idea that you’re doing a physical exam. You’re not. You’re replacing the actual in-person exam with mostly subjective findings – often patient-elicited.
Utility of the Physical Exam
Do you need a physical exam on a SOAP note? Maybe. Probably not. But if you’re documenting for billing purposes, it’s a good idea.
If you’re running your own private virtual practice or you don’t have to do any billing, such as with most DTC telemedicine companies, there is no need to perform this half-assed physical exam.
But, the physical exam could get you out of some pickles. You can always decrease your telemedicine risk by commenting on things which might come up during an investigation.
If the patient was short of breath or speaking in tongues, it’s worth mentioning it if you think it will help justify why you wanted to send them to the ED. And document why the patient was AMA for not wanting to go.
Also, if you document that the patient was NOT in distress, had no cough on the phone, spoke full sentences, etc, that’ll show that there was no signs of distress.
A patient who “is not actively vomiting” can’t later go and say that I was vomiting non-stop. After all, they had a conversation with you on the phone and didn’t throw up during that interaction.
Telemedicine Physical Exam Template
You can find all sorts of documents published by various telemedicine sources which are trying to recreate the in-person physical exam.
In my opinion, this can get a little out of hand. Is your patient really going to be able to appreciate rebound tenderness? Do you even want to rule out appendicitis based on a telemedicine physical exam?
The best template to follow is one you can stand behind in a courtroom. What you can observe on a video visit and what you can have the patient do should be the extent of your telemedicine physical exam template.
Here is a list of what you should be able to determine based on a telephone visit:
- no sign of distress
- no signs of respiratory distress
- speaking full sentences
- alert and oriented
- organized thought pattern
- no coughing on the phone
- no wheezes audible
- voice is clear, speech not slurred
Here is a telemedicine physical exam template for a video visit:
- all of the above
- symmetric spontaneous facial muscle movement
- no gross pupillary abnormality
- no rash noted on face
Here is what you could elicit based on some instructions:
- pupils symmetrical
- no skin rash, no skin lesions
- normal spontaneous muscle movement of all extremities
- normal gait
- no tremors
- tender over…
- no foreign body noted in …
- no nail discoloration
- oral exam normal
- no tonsilar exudates
That’s pretty much it.
I know you can get a lot more. But, again, what are the diagnoses we want to rule in/out with a telemedicine physical exam? It might be best to leave a more thorough exam for the post-covid, in-person visit.
Specialty-Based Telemedicine Physical Exam
If you’re a gynecologist or rheumatologist or dermatologist then you might be able to get a lot more granular. Still, a joint effusion versus enthesitis versus subcutaneous mass is hard to differentiate. I’m not sure I’d want to be responsible for that based on a telemedicine physical exam alone.
Reviewing a Photo
I’ve come across many telemedicine SOAP notes where the provider didn’t review the photo which was uploaded.
Much like an xray, you’re responsible for reading the image. Anything that’s on there, you’re responsible for.
Reviewing an image and your observations of it are the subjective part and considered and part of this quasi physical exam.
Whether it’s a photo of passed blood clots, stool sample, vomitus, rash on the lips, or swelling of the legs, you should document your impression and your findings.