💻 Telehealth Visit Protocol — Structure For Quality Virtual Care

Telehealth Visit Protocol: Primary Care HTN/DM Follow-Up, 40-Min Virtual

A telehealth visit protocol produces structured workflow maintaining clinical quality. This design: pre-visit prep + 40-min structured visit + clear documentation + follow-up.

Pre-Visit Workflow (Day Before + Day Of)

48 Hours Before:

• Appointment reminder email + SMS with:

- Join link

- Pre-visit intake form

- Tech check link

- Home BP + glucose reading request

• Patient completes intake via MyChart
• Patient tests connection via platform's tech check tool

24 Hours Before:

• Nurse reviews intake + labs
• Nurse prepares pre-visit huddle summary for provider
• Patient receives reminder to have BP cuff + glucometer ready

30 Minutes Before:

• Patient receives 'visit starting soon' reminder
• Patient prepares: good lighting, quiet space, medications ready
• Staff confirms technology working

5 Minutes Before:

• Patient clicks join link
• Virtual waiting room
• Provider receives notification

Visit Structure (40 Minutes)

Phase 1: Opening + Tech Check (0-3 min)

• Verify patient identity (visual + name confirmation)
• Confirm location (state-specific licensing matters)
• Confirm private setting
• Brief connection check
• Welcome + agenda setting

Phase 2: Chief Complaint + Interval History (3-8 min)

• 'How have you been since we last spoke?'
• Review home monitoring data
• Medication adherence check
• Any new symptoms or concerns
• Adverse effects review

Phase 3: Focused Review of Systems (8-12 min)

• Cardiovascular: chest pain, palpitations, edema
• Endocrine: polyuria, polydipsia, weight changes
• Neurological: vision changes, numbness/tingling (DM)
• GU: frequency (DM relevance)
• Medications: side effects

Phase 4: Virtual Physical Assessment (12-18 min)

• Visual: appearance, alertness, acute distress
• Vital signs: patient-reported (with home cuff) — verify technique
• Visible extremities: edema check, skin color
• If patient has digital tools: glucose + BP demonstrations
• Can instruct patient through: abdominal palpation, lymph node check (limited)
• Document what CAN'T be assessed virtually (auscultation, full exam)

Phase 5: Review Labs + Data (18-25 min)

• Share screen showing lab results
• Discuss A1C trajectory
• Review home monitoring logs if patient has
• Explain changes + implications
• Compare to prior visit

Phase 6: Assessment + Plan Discussion (25-35 min)

• Clinical reasoning shared with patient
• Diagnosis/problem status
• Treatment options discussed
• Medication changes if needed
• Patient questions + concerns
• Written plan created (sent via portal)
• Lifestyle recommendations

Phase 7: Next Steps + Follow-Up (35-40 min)

• Orders: labs, imaging if needed
• Follow-up schedule (in-person vs. virtual)
• Emergency symptoms to watch
• Portal messaging expectations
• Summary sent via secure message
• Patient confirms understanding
• Close visit

Clinical Assessment Limitations

Document what cannot be fully assessed virtually:

Cannot reliably assess:

• Auscultation of heart, lungs, abdomen
• Physical palpation
• Neurological reflexes
• Detailed musculoskeletal exam
• Ophthalmologic detail
• Otoscopic examination
• Laboratory tests (unless home-drawn)
• Most procedures

Can assess (with patient cooperation):

• Visual appearance + distress
• Speech + cognition
• Range of motion (visible)
• Skin appearance
• Home-monitored vital signs
• Medication administration
• Patient-reported symptoms

Document explicitly:

'Physical examination limited to virtual assessment. Full cardiac, pulmonary, and abdominal examination not performed. Recommend in-person follow-up if [specific concerns emerge].'

Documentation Requirements

Include in note:

Standard SOAP format +

Telehealth-specific:

• Platform used (Epic MyChart)
• Patient location (home, state)
• Provider location
• Patient privacy confirmation
• Limitations of virtual examination
• Technology functionality
• Any privacy concerns

For billing (Medicare + commercial):

• Modifier 95 (synchronous telemedicine)
• POS 10 (patient home) or POS 02 (other)
• Time spent
• Patient verbal consent for telehealth
• Originating site + distant site

Sample documentation:

'Telehealth visit via Epic MyChart video. Patient at home in [State]. Provider at [location]. Patient verified identity + consented to telehealth. Visit conducted over video with audio. Physical examination limited to visual assessment — full auscultation + palpation not performed. Total time: 40 minutes.'

Follow-Up + Handoffs

Clear follow-up path:

In-Person Follow-Up Indicators

• New symptoms requiring physical exam
• Abnormal vitals not explained by virtual review
• Medication titration that requires in-person monitoring
• Procedures needed (labs, injections, etc.)
• Patient preference

Next Virtual Visit Appropriate

• Stable chronic disease management
• Medication adjustment + tolerance check
• Test result discussion
• Minor concerns
• Patient convenience (travel difficulty)

Post-Visit Actions

• Summary sent via portal
• Prescriptions sent to pharmacy
• Lab orders transmitted
• Referrals sent
• Follow-up appointment scheduled

Emergency Protocols

When to direct patient to ER:

Symptoms requiring immediate attention:

• Chest pain, pressure, or tightness
• Severe shortness of breath
• Sudden weakness or paralysis
• Severe headache (especially sudden)
• Signs of severe hypoglycemia (for DM patients)
• Uncontrolled hypertension with symptoms

During visit:

• Stop virtual visit
• Call 911 or direct patient to call
• Stay on video until help arrives if possible
• Document extensively

Written emergency protocol:

• Patient should have provider's direct number + office number
• After-hours nurse line information
• Clear instructions for when to call 911
• Patient demographic info with 911 operator if needed

Platform + Tech Setup

Epic MyChart video visit:

Provider setup:

• Quality webcam (1080p)
• Good lighting (ring light or natural)
• Quiet professional background
• Wired internet preferred
• Dual monitor: video + EHR
• Headset with microphone
• Privacy (closed door)

Patient requirements:

• Device with camera (smartphone, tablet, computer)
• Stable internet
• MyChart app or web access
• Private location
• BP cuff + glucometer (for this patient)

Pre-visit tech check:

• Provider does daily tech check
• Patient tests connection via platform before first visit
• IT support available for connection issues

Backup plan:

• If video fails: audio-only visit
• Reschedule to in-person if needed
• Document technical difficulties

Reimbursement Compliance

Medicare (post-COVID permanent changes):

• Most telehealth services permanently covered
• Most geographic + originating site restrictions removed
• Home is appropriate originating site
• Audio-only allowed for some services
• Appropriate CPT code + modifier 95
• POS 10 for home, 02 for other

Commercial insurance:

• Coverage varies
• Many at parity with in-person
• Verify specific plan coverage

Documentation requirements:

• Patient verbal consent for telehealth (documented)
• Time spent
• Services provided
• Platform used
• Both provider + patient location

Billing tips:

• Check patient's specific plan coverage
• Document thoroughly
• Use appropriate codes (99213, 99214 etc. + modifier 95)
• Time-based billing if appropriate

Key Takeaways

• 40-min structured visit: opening (3m) + history (5m) + ROS (4m) + virtual exam (6m) + labs review (7m) + plan (10m) + follow-up (5m). Rigor matches in-person.
• Document telehealth-specific elements: platform, patient location, identity verification, privacy, examination limitations. Required for billing + legal protection.
• Clinical assessment limits: document what CAN'T be assessed (full auscultation, palpation). Patient consent + understanding of limitations.
• Clear follow-up path: in-person if new symptoms or exam needed. Virtual for stable chronic disease management + test result discussion.
• Emergency protocols: pre-identified symptoms requiring ER (chest pain, stroke symptoms, severe dyspnea). Direct patient to 911. Document extensively.