procedure follow up - tele health

OVERALL_INSTRUCTIONS

Chief Complaint

[Insert chief complaint or reason for consultation]

Template

Telehealth (Audio-visual visit) Progress Note PATIENT NAME: [Insert Patient Name] MEDICAL RECORD #: [Insert Medical Record Number] DATE OF BIRTH: [Insert Date of Birth] SUBJECTIVE: [Organize the section by listing each condition in separated paragraph, followed by a detailed narrative description. For each reported condition, provide a detailed narrative including the following: current status, any recent changes or episodes, lifestyle modifications, and relevant personal or family medical history. Include specific details such as triggers, symptoms, and management strategies.] OBJECTIVE: [Insert objective findings] DIAGNOSTICS: [Pertinent Diagnostic Studies: [test date] [Insert diagnostic findings and procedure findings verbatim from uploaded documents, don't change word]] ASSESSMENT / PLAN: [Insert diagnoses, ICD 10 code and management plan, organized by each diagnosis in one numbered item] AUDIO-VIDEO VISIT CONSENT: The patient has given verbal or written consent for delivery of health care, via telehealth through a Video Visit appointment. Patient was using real-time Telehealth tools between my location and the patient's location which is confirmed to be in California. Prior to discussing medical issues, the patient provided informed verbal consent to perform this consultation using Telehealth tools, and all questions about the Telehealth interaction were answered. • Patient confirms they are located in a safe location and within the state of California: Yes • Patient states location at time of video visit is at home [address confirmed by MA]. • Patient confirmed date of birth and the phone number where they can be reached in case Audio and/or Video visit is disconnected. Thank you for allowing me to participate in the care of this patient. If there are any questions or concerns feel free to contact me (925-776-7600).