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April 23, 2020
The Physical Exam Via Telemedicine
By Beth Faiman PhD, MSN, APRN-BC, AOCN®, FAAN, Cleveland Clinic Taussig Cancer Center
Our world has been turned upside down from the coronavirus, and I worry how this impacts my patients’ care. Patients with cancer can rarely “miss” scheduled infusions because of the current crisis. “Stable” patients may omit important follow-up visits to avoid travel, and some may forgo reporting new concerns that may indicate relapsed disease.
Many of my patients, however, look forward to follow-up office visits. We catch up on family.
“How was your Florida vacation? Where are you traveling to next?”
Connecting With Patients During the COVID-19 Pandemic
In a brick-and-mortar cancer center, patients, caregivers, and health-care providers are able to connect. If I give them bad news, I can provide good eye contact and put my hand on theirs to display empathy. I walk them to the scheduling desk to make their next appointment. They are led to the treatment area with printed instructions on how to take their medications and when to return to see me or other providers. Patients will often bring these detailed records to future appointments.
Now, my patients are unable to travel to our cancer center, unless there is an urgent need. So, no hand-holding can occur. No printed instructions so they don’t misunderstand their health.
How can I effectively provide care remotely during this crisis?
Fortunately, telehealth visits are on the rise. A virtual visit allows patients to see an advanced practitioner, physician, or other health-care provider that allows a diagnosis from home. Prescriptions can be sent to the pharmacy
when appropriate. X-rays and appropriate tests can be ordered based on the virtual visit and are often performed before a scheduled encounter so the results can be discussed. And our hospital, like many, has waived all
fees and copays regardless of insurance coverage.
So, why not encourage patients to continue with social distancing and try the remote visit option? After all, one’s home environment may be a safer place than the cancer center for them to discuss their concerns without the stress of driving to a provider’s office.
Steps to a Virtual Visit
The flow of my virtual visits are structured similarly to my in-person visits: introduction, history of current illness, subjective exam, physical exam, assessment of clinical information (labs, x-rays, etc.), then the impression and plan.
Here are some things that I have learned over time about conducting an examination via telemedicine.
1. Choose a Platform
First, it is important to know what counts as a virtual visit. While my institution uses an application via the American Well company, there are many other device options. Due to the current pandemic, Google Duo and FaceTime are also appropriate to conduct an encounter.
2. Maintain a Professional Appearance
Of course, professionalism continues to be important. Wear professional attire and silence phones to give all your attention to the patient. Before you connect and turn on your video camera, set the camera at eye level and make good eye contact with it.
3. Ensure the Technology is Working
When the patient connects, introduce the technology and ask, “Can you hear and see me ok?” Demonstrate comfort and confidence in the technology (regardless of how you are feeling about it) to help patients feel at ease and focus on their care, as opposed to focusing on the virtual modality. Emphasize why telemedicine is the safest option for the patient given the current public health crisis by stating,
“Virtual visits are a safer and more convenient way for you to be assessed. I hope you will find this to be a great way to connect.”
Establishing and conveying value
and respect to the patient is important. When patients feel like you see them as a person, you create a safe space that invites their trust. They are often more open to exchange health information.
4. Set the Agenda
Now is where I collaboratively set the agenda and ask the patient, “What are your concerns, and what would you like to talk about today?”
I review the flow of the visit and inform them that, just like in the office, I will complete my subjective review of systems doing the head-to-toe exam.
5. Take Vital Signs
Next, I ask if they have a blood pressure machine or thermometer at home so I can assess and record vital signs. If not, that is ok. I ask them if they know how to check their pulse and show them how to count the number of heart beats if not. That way, they are not saddened that they do not have the requested technology.
I also ask if they’re diabetic and what their last blood glucose was.
6. Conduct a Physical Exam
Now onto the physical exam. Skeptics will criticize this part, and say a good physical exam is not possible unless you are face to face. Yet, if an astute practitioner provides good instructions and effectively explains what you want them to do, a good exam is entirely possible. And, only two systems are required to be documented for billing purposes.
Things to assess: Is the patient alert and oriented, or confused and disheveled? The fact that they were able to enable video technology is a positive finding.
Have them show you exposed skin. Ankles. Do they have headaches? Ask them to tap on the sinuses.
Are they constipated or have diarrhea? Ask them to press on their abdomen to elicit any tenderness. Swollen ankles? How swollen? Can they point the camera to their extremities to see if one leg is more swollen than the other? Are
they having back pain or worried about gait? Have them walk around the room and show you to the best of their abilities the painful area. Ask the patient if they have a blood pressure machine and to check and report.
My institution provides a template, which I adjust based on my needs. See below how I would document a follow-up encounter via video exam for a patient with ankle swelling.
VIDEO EXAM: (if completed, performed via video enabled technology)
Vital signs: BP 120/62 P 82BPM T98.6F. All recorded by the patient using their personal equipment.
GENERAL: alert and appropriate, in no distress, well-hydrated, well-nourished and happy, smiling, interactive
SKIN: no rash noted
HEAD: normocephalic, no abnormality or lesion noted
EYES: no injection and visual acuity is grossly normal
EARS: external ears normal, no mastoid tenderness
NOSE: external nose normal without rhinorrhea
OROPHARYNX: moist mucus membranes, no tonsillar hypertrophy/exudate, uvula midline and pharynx non-erythematous, lips, teeth and gums are without obvious lesion
NECK: full ROM, no cervical LNs noted
RESPIRATORY: breathing non-labored and no grunting/flaring/retractions
CHEST: equal chest rise with normal respiratory effort
HEART: heart rat 82BPM from vital signs
ABDOMEN: soft and non-tender
BACK: back normal in appearance, spine with FROM
EXTREMITIES: edema +1 bilateral LE
NEUROLOGIC: no obvious deficit
Additional Thoughts
- Spend time with your patients. Don’t rush. Patients are at home and in a place where they are comfortable.
- Ask lots of questions and allow the opportunity for the patient/caregivers to ask questions.
- Ask upfront if they have a pen and paper to write down what you talked about. Let them know that an electronic message with instructions on when to follow up can be sent.
- Make sure the patients disconnect from the visit first so they are able to ask about anything they wanted to talk about. This provides closure and eliminates the worry that they forgot to ask an important question. Say things like, “I’m so thankful that you connected with me today and didn’t wait to share your concerns. I will put a note in your chart. I hope you had a good visit and that you’ll consider another virtual visit in the future.”
Engaging patients in a virtual encounter is a valuable part of today’s current practice. I hope you will take with you some clinical pearls and a renewed confidence in being an empathetic and effective telehealth provider.
Read more from the APSHO Advance: Special COVID-19 Series
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