Documentation for Teleconsultations
Anay Shukla
Founding Partner, Arogya Legal – Health Laws Specialist Law Firm
Eshika Phadke
Associate, Arogya Legal – Health Laws Specialist Law Firm
The legal significance of well-maintained medical records cannot be emphasized enough. Especially for telemedicine where the jurisprudence is still in its primitive stages, it is of utmost important for doctors to maintain detailed records of their teleconsultations.
The Telemedicine Practice Guidelines 2020 specify the minimum information that must be documented in a patient’s telemedicine records. In this article, we outline the mandatory information that should be recorded, as well as additional best practices to ensure maximum legal protection.
Patient’s Location
It is advisable to record where the patient is located at the time of consultation. In the event that the patient is situated in a place where the doctor is not licensed to practice, he/she should refrain from continuing with the consultation, and should advice the patient to seek medical advice from a licensed professional. If the patient is a regular patient of the doctor who is temporarily located outside of the area where the doctor is licensed, the doctor may, if he deems necessary, proceed with the consultation, and should note down the peculiarity of the situation in the patient’s records.
Patients Consent
Explicit consent must be sought from the patient if the consultation is being initiated by anyone other than the patient (such as a relative, friend, another doctor or a health worker). The doctor may elect to have the patient state his/her consent during the consultation or send their consent via email, text message or an audio/video recording.
If the patient is a minor or mentally incapacitated, a guardian or caregiver may consent on their behalf. The identity of such person should be ascertained and recorded along with the consent.
If the doctor wishes to record the sessions, explicit written consent must be sought from the patient for recording and storing the session.
Patient information
If the doctor requests any identity or age proof in the course of the consultation, details of the same should be noted. The doctor must maintain records of the patient’s case history, doctor’s notes, investigation reports, images, etc that they rely upon to arrive at a diagnosis or treatment plan.
If the patient shares information about pulse, blood oxygenation, blood pressure, blood sugar, etc which they/their caregivers have recorded, it is advisable to record what device was used for measuring the levels.
Logs
The doctor should record how the consultation was carried out, and maintain the logs of the same for future reference.
During the course of the consultation, if the doctor deems that it is necessary to change to another mode of consultation (from text/audio to video or in-person), the reasons for same should be recorded. If the patient refuses, the doctor should be sure to capture the same in their records.
Prescriptions
The doctor may either issue a signed paper-prescription and share a photograph or scanned copy of the same, or issue an e-prescription. A recommended format has been annexed to the Telemedicine Practice Guidelines. The doctor must maintain copies of all prescriptions that are issued as he/she would for in-person consultations.
Comprehensive Records
Note that if the teleconsultation is taking place across various mediums (for example, the initial discussion over voice call, prescription for pathology tests issued over text message, results shared via email, etc), the doctor should ensure that copies of all communications and records are stored in a common folder, along with any records from in-person consultations, so that the records for the patient are complete and easily accessible.
The background to the Telemedicine Practice Guidelines 2020 specifies that one of the key advantages to telemedicine is a higher likelihood of maintenance of records and written documentation. Thus, while it may seem cumbersome to maintain detailed records of telemedicine consultations, the law expects meticulous documentation.