Do you need to document a 2.6 second pause on a telehealth (telehealth) call?

Documentation Requirements for Telehealth Cardiac Pauses

A 2.6 second pause observed during a telehealth visit should be documented in the patient's medical record, as it represents a potentially significant cardiac finding that requires documentation for proper patient care and follow-up.

Telehealth Documentation Standards

• Telehealth visits require the same standard of documentation as in-person visits, with documentation of informed consent for telehealth and all clinically relevant findings 1.
• Organizations providing telehealth services should follow standard operating policies and procedures regarding documentation requirements, ensuring compliance with relevant legislation and regulations 1.
• Documentation should include a disclaimer such as "teleconsultation is provided with the consent of the patient" 1.

Significance of Cardiac Pauses

• A 2.6 second pause is a clinically significant finding that warrants documentation and potential follow-up, as cardiac pauses can be associated with syncope and other adverse outcomes 1.
• The American Heart Association recommends careful documentation of cardiac rhythm abnormalities, as they may indicate need for further evaluation or treatment 1.

Documentation Requirements for Telehealth Cardiac Findings

• When cardiac abnormalities are observed during telehealth, documentation should include:

  • Duration of the pause (2.6 seconds in this case) 1
  • Context in which it occurred 1
  • Associated symptoms, if any 1
  • Plan for follow-up or further evaluation 1

• For cardiac rhythm abnormalities observed via telehealth, it's important to note the potential limitations of telehealth monitoring, including possible latency in ECG displays 1.

Follow-up Considerations

• Documentation should include a clear plan for follow-up, which may include:
  • Referral for in-person evaluation with hard-wired monitoring 1
  • Consideration of Holter monitoring or other ambulatory cardiac monitoring 1
  • Scheduled follow-up to assess for recurrence or progression 1

Important Caveats

• Telehealth systems may have latency (delay) in displaying cardiac rhythms, which could affect the accuracy of timing measurements 1.
• For definitive assessment of significant cardiac pauses, the American Heart Association recommends using hard-wired monitors rather than wireless telemetry systems, which should be documented if follow-up is needed 1.
• Documentation should acknowledge the limitations of telehealth assessment for cardiac rhythm abnormalities and indicate if confirmation with direct monitoring is recommended 1.

Best Practices for Telehealth Documentation

• Documentation should be electronic in compliance with privacy and data protection regulations 1.
• Telehealth documentation should be as thorough as in-person documentation, with clear indication that the encounter occurred via telehealth 1.
• Documentation of cardiac findings should be completed promptly to ensure timely follow-up for potentially significant findings 2, 3.