Best Practice Guidelines: Telehealth Practice Management
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6. Consultation phase
6.7. Clinical History & Reports
As a practitioner, you are legally required to keep a patient’s health records for no less than 6 years and up to 20 years in the case of certain specialties or minors. For this purpose, you may consider using a platform that automatically stores and groups patients ' clinical information on each patient’s profile.
A patient’s clinical history can also be used as a tool throughout the consultation process to assist with the following:
- It gives you context about the patient’s past conditions and treatments
- It allows you to better understand the patient’s current conditions
- It allows you to better diagnose the patient’s condition
- It helps you to fine-tune your treatment plan
- It assists you with fine-tuning scripts, according to what your patient has preferred to use in the past or to use different medication than previously scripted, because the patient may have had a bad reaction to some of the medication
- It may help you decide what special investigations you need to consider to help with diagnosis
- And it assists you with the analysis of special investigations and medical reports such as pathology and radiology reports
Clinical History
A patient’s clinical history is compiled with all of their past clinical documents.
A patient’s clinical history can assist the practitioner with the treatment of the patient by giving the practitioner a view of the patient’s treatment over a specific time period.
The patient’s clinical history is displayed as a timeline of clinical events (i.e. scripts, sick notes, general examinations, pathology, etc). All clinical history events can be emailed, printed and viewed. Some events can be edited and others like scripts
can be copied to a new event of the same type. Some events (e.g. general examinations and pathology) contribute plottable data to the patient’s clinical history and that data can then be viewed from the clinical history in graph/table format so that
similar data for a specific period can be easily compared.
Telehealth consultations will keep record and the clinical notes that were completed will be available. Telehealth consultation is allowed to be recorded according to the HPCA laws only when the practitioner has written or voice recorded permission from the patient. Ensure all legal precautions are in place when a Telehealth consultation is recorded.
Clinical Reports
Clinical reports can be used for letters, such as referral letters, motivation letters, sick notes and much more.
Templates can be used to create any type of letter or clinical report.
The history of a patient is collected and stored so that the practitioner can view it to have an overview of the patient's medical status.