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.
6 replies on “Telemedicine Physical Exam Template”
very handy. Thanks!
Great write up. To the point. Thank you.
Given the aim of the information in this article is partially to reduce liability, have you considered recording and archiving your sessions?
Additionally with your interest in data, there could be many possibilities for using that repository beyond defending yourself legally and reviewing as needed…
Working with data scientists, there could be potential to analyze for all sorts of interesting patterns in the video/audio… E.g. facial expression, movement, voice properties (tone, prosody, rate), speech content, etc.
Back when I initially became interested in Ginger.io, I knew them for their idea of using data from smart phone sensors to predict variations from baseline mental health… E.g. increased sleep, decreased messaging with social contacts, decreased exercise (all features that can be derived from sensor data)… Uh oh is my patient becoming depressed? Ginger.io can alert the patient (digitally supported insight) and notifythe care team to check in.
Anyway, having a repository of data to be processed can be interesting and potentially lucrative… Also many great historical scientists were more rigorous data collectors than is focused on as we learn about them. E.g Mendel… And Galileo really depended on the observations and data from Tycho Brahe to have his breakthrough.
Lots of great data out there but collecting it is one hassle and storing it is another. Once data laws change then you’ll have to make changes to your storage and guidelines accordingly. I believe it’s too difficult for a sole physician to undertake this. And often if there are any other 3rd parties involved then data collection can be a legal nightmare. There is a lot of great data modeling being done with patient voice, patient gestures, and other such data but having access to a large enough repository in order to train a ML model seem impossible at this time.
Thank you for a well written article. I’m all for healthy technology and certainly for it when it aids the elderly and handicapped. However, 25 years of nursing has taught me being in the same room with the patient for something like a P.E. or other kinds of visits are absolutely necessary. The overall assessment and sense, or gut feeling we get that only an in person interaction between people occur. I discovered a severe case of ppd/pnd by noticing a patient had her hair up due to it being so matted from depression. She believed her child left her no time to bathe and was building quite a delusional resentment toward the 4 month old. Very specific Im aware. But how many things will be missed when human interaction is missing? Do we not already see the results in children and teens physically and mentally due to lack of social in person interactions? No eye contact, socially inept, pale, sleep issues, massive social anxiety, worsening eye issues with earlier onset. How any thousands and thousands of children have never returned to school since it was closed. Parents are struggling and suffering with their childrens well being. Unaware that this technology MUST be taken from our children or greatly decrease their time on it. All the above is without mentioning what blue light toxicity and the irradiation they’re experiencing while on these devices. Non ionizing was first called harmless, then woops it’s a 2b carcinogen, then woops our calcium voltage channels can’t regulate properly due to device use, then woops the bundle branch block is affected as well. Woops it displaces water in our body, just like a cold spot when you microwave food and have to stir it. Our cold spot becomes a nighttime leg cramp. Hmmm what if we’re full of heavy metals in the magnetic field? There’s a thought for our food fortifying country. We’re so iron toxic our blood serum levels read low because our body is attempting to offload it by going into our tissue. Then you get diagnosed with anemia and start supplementing more iron! I may appear nasty, I hope not but as medical professionals we need to wake up and wake up others to the truth and big picture. We are not meant to live among these non native rf waves. Please understand if you have wifi you are LITERALLY living as if you are in an operating microwave. Not a lil like. Precisely like. But worse because it’s exceeded 2.4 ghz which is what our food cooked at. I saw the new 5G meter measurements. Under a tower is was 2-3 mws, a few feet away it went into the hundreds. However, it’s measurements while watching a YT video fluctuated between 300-1016 mws. Yes, one thousand and sixteen. A phone call connection the same and remained between 600-800 mws after connection. That is not an interesting fact that is murder and a glioma, heart attack, diabetes, CLOT made of iron and magnesium waiting to happen. Diabetes? Yes, it causes insulin resistance and sugar spilling. Lepton resistance as well. So all this diet advice is well intended but doesn’t mean a thing living in this emf soup and using led bulbs that kill our vital circadian rhythm, cause eye disease, have people afraid to drive at night. And all the above of course messes with our hormones and causes infertility. Win win for those who don’t want to see the population grow no? Where will you stand during this time in history? Read The Invisible Rainbow by Arthur Firstenberg. You’ll realize 2020 wasn’t much different than the 1918 “ Spanish” flu. But the people who spoke the truth then were called Hyster-terical and made to appear crazy. If they kept trying to get the truth out hysterectomy was performed. Later they created the term “conspiracy theorist” which was incredibly effective at having people believe if you’re shot from the back you fall backwards, and vice versa. They’ve been killing us since the telegraph, then the radar. Ac used when dc would have been much better. Drive a Tesla? Cancer mobile. A doc was asked to leave when he went in with an emf meter. The baby seat had the lowest number at 65mws. The baby seat. He’s also put up the satellites and owns the neurochip. So let’s not fall for him and his Twitter distractions. He put out info he was permitted to and knew nothing would be done about. He’s kicked off 3 people I’m aware of so far. A free speech ABSOLUTIST would not do that. You don’t get access to our skies and under our tunnels unless you’re playing with “elitists” or compromised people. All I can ask of the medical community is to please read the aforementioned book. Also The Fourth Phase of Water. When was the last time this winter you saw a blue sky with natural cloud formations? Our skies were not grey everyday. And the sun is not trying to kill us, quite in the contrary.
This is a very thorough SOAP note. Though it’s important to separate objective and subjective points; opinions are best kept for the assessment section.