Statement of Ongoing Appropriateness of Videoconferencing for Patient
In efforts to ensure ongoing safe and ethical care, the provider can indicate in the documentation that they have an ongoing evaluation of the patient (Luxton et al., 2016, chap. 6; Smucker Barnwell et ah, 2018). This evaluation should consider not only the patient’s emotional and behavioral status, but general risks, adherence to medication regimen if pertinent, physical ability, and other stressors that may impede therapeutic processes. In doing so, the provider can document that they had been proactive in ensuring safe and effective videoconferencing care. This statement can be built into the clinical session summary narrative by indicating:
“As based upon [observations of clinical presentation in sessions, self- reported status, rating scales], [patient name] appeared to have minimal risk and continues to present as an acceptable candidate for videoconferencing services.”
Should the patient present with a concern that may lead to the provider pausing or terminating videoconferencing, documentation could read:
Due to [patient name]’s reported [increase in challenging behaviors or risk-related factors, difficulty finding a private space for the videoconferencing sessions, technological issues that preclude the videoconferencing sessions], the provider and patient discussed the provider’s concerns with ongoing videoconferencing. It was collaboratively decided that due to recognized issues, the use of distance videoconferencing will be paused in favor of [alternatives such as F2F visits, telephone calls]. Use of videoconferencing will be re-evaluated as based upon need and appropriateness as sessions progress.
Statement of Verification of the Patient’s Identity
As providers should verify the patient’s identity prior to discussing any confidential information, especially if an initial session without a prior F2F meeting, such processes should be documented (Luxton et al., 2016, chap. 6). Such documentation could be brief and read:
“Identity of [patient name] was verified via state-issued photo identification held to the video camera.”
Emergency Contact Information
Providers should always have emergency contacts and an emergency plan available when conducting videoconferencing, as one never knows what may occur (APA, 2013; Gamble et al., 2015; Shore & Lu, 2015; Smucker Barnwell et ah, 2018). If the information is readily available in their full medical record, a statement could read:
Emergency contact information including the address, phone number, and email for [patient name], alternative contacts, the nearest medical center, and the nearest law enforcement center were gathered at the onset of treatment and are available in [patient name]’s medical record.
While not essential, the provider may alternatively include such emergency contact directly into the individual note if it is easier to locate should the medical charting or EHR be more complex and take time to sift through to find the necessary information.