Initial Contact-Specific Documentation
While all aforementioned detail should be considered for inclusion in any general videoconferencing documentation note, when conducting an initial contact and collecting informed consent, additional information should be recorded. This information should clearly indicate that the provider considered multiple factors and took necessary ethical and legal steps prior to beginning full videoconferencing services. Information can be separated by content. First is an indication of why videoconferencing was selected for the specific patient. This statement can be near identical to those listed in the “Rationale for Videoconferencing Being Rendered” section, or modified with more detail for the individual’s unique situation. For example,
Videoconferencing will be utilized for future sessions due to [patient name] living approximately [distance] from the provider and no similar services being available in [his/her] vicinity. Videoconferencing services will allow the provider and [patient name] an ability to both see and hear each other in real time.
Second should be an indication that the patient was screened for appropriateness. An example of this could read;
Prior to the provider and [patient name] agreeing on videoconferencing services, [patient name] was screened for appropriateness as based upon several factors that align with the American Psychological Association and American Telemedicine Association recommendations, including [patient name]’s technological knowledge and attitudes, past experiences with both mental health and technology-enhanced treatments, availability of appropriate videoconferencing technology, diagnostic considerations, physical disabilities or limitations, access to F2F providers, and possibility for safety concerns.
While this information can be modified and shortened, it is meant to convey that the provider is not only aware of the literature guiding appropriateness, but that they did their due diligence to screen the patients for the videoconferencing. Third, the provider should clearly document the informed consent and safety planning processes (described in Chapter 4). This detailing may include a general statement that informed consent information was reviewed and the patient provided their consent, or can include specific detail of what was covered as part of the informed consent process. An example of the more specific detailing could read,
[Patient name] signed a telehealth-specific informed consent form that detailed pertinent information, including strengths and limitations of the approach, scheduling information, payment details, and communication strategies between sessions, as well as an emergency contact form that included the local hospital and law enforcement office of [patient name] to plan for any potential crises. [Patient name] also agreed to update the provider prior to the onset of the session should [he/she] ever be out of the state of the provider’s license. See medical record for copies of paperwork. Information was also provided verbally.
Fourth, while not essential, it may be prudent to include a statement that the provider will supply the videoconferencing as long as it is helpful and safe. Should the services no longer be reasonable, optimal, or safe, the provider has the right to cease the videoconferencing services in favor of a more beneficial and/or safe alternative. This clause could read:
It was discussed that if at any time the provider believes that the video- conferencing method is no longer effective or beneficial, or if there is an increased potential for harm to [patient name] or another individual as a result of the continued videoconferencing, alternatives will be discussed, with referrals provided as necessary.
Finally, the provider may wish to document that a safety word/phrase (detailed in Chapter 4) was created. See Figure 15.2 for an integrated summary of such information.
