What is a recommended template for a telehealth physical exam?

Telehealth Physical Examination Template

A structured telehealth physical examination should include guided patient self-examination components organized by body system, with clear documentation that certain examination elements cannot be performed remotely and require in-person follow-up when clinically indicated. 1

Pre-Visit Setup and Environment

Technical Requirements:

• Use laptops or desktop computers rather than cell phones for optimal visualization 1
• Ensure adequate lighting with camera positioned at eye level 1
• Verify quiet, private environment for both provider and patient 1
• Confirm good audio quality before beginning examination 1
• Have patient alone or with one assistant who can help with technical issues 1

Documentation Requirements:

• Document informed consent for telehealth encounter with disclaimer: "teleconsultation is provided with the consent of the patient" 2, 1
• Note that physical examination is limited by telehealth modality 3, 1
• Document all findings with same thoroughness as in-person visits 2, 4

Systematic Examination Components

General Appearance and Vital Signs

• Visual assessment: Overall appearance, distress level, body habitus, grooming 5
• Patient-reported vital signs: Request patient measure and report temperature, heart rate, blood pressure if home equipment available 2
• Orthostatic vital signs: Guide patient through position changes (lying to standing) while monitoring for symptoms 6

Head, Eyes, Ears, Nose, Throat (HEENT)

• Eyes: Assess pupil symmetry by having patient look at camera in bright then dim lighting; evaluate extraocular movements by having patient follow your finger on screen 5, 6
• Ears: Limited visualization unless patient has home otoscope device 7
• Nose/Throat: Have patient open mouth wide toward camera for gross oropharyngeal assessment 5
• Lymph nodes: Guide patient to palpate neck, submandibular, and supraclavicular regions, reporting size and tenderness 1

Neurological Examination

• Cognitive assessment: Mini-Mental Status Exam is highly reliable via telehealth 5
• Cranial nerves: Test facial symmetry (smile, raise eyebrows), tongue protrusion, shoulder shrug 5, 6
• Motor function: Observe gait if space permits; assess arm drift with eyes closed; finger-to-nose testing 5, 6
• Coordination: Rapid alternating movements, finger tapping 5
• Balance: Romberg test if patient has spotter available for safety 6

Cardiovascular Examination

• Inspection: Assess for visible jugular venous distension, peripheral edema by having patient press shin and show camera 2
• Auscultation: Requires electronic stethoscope with transmission capability; otherwise defer to in-person visit 7
• Peripheral pulses: Guide patient to palpate radial and dorsalis pedis pulses bilaterally 1

Respiratory Examination

• Inspection: Observe respiratory rate, work of breathing, use of accessory muscles 5
• Auscultation: Requires electronic stethoscope; cannot be performed adequately without peripheral device 7
• Oxygen saturation: Request reading if patient has home pulse oximeter 2

Musculoskeletal Examination

• Range of motion: Guide patient through active movements of affected joints 5, 8
• Strength testing: Demonstrate resistance exercises patient can perform against own body or household objects 5
• Gait assessment: Observe walking if adequate space and safety measures present 8
• Palpation for tenderness: Guide patient to palpate specific anatomical landmarks and report findings 1

Skin Examination

• Rash assessment: Have patient position affected area close to camera with good lighting 7
• Wound evaluation: Assess size, drainage, surrounding erythema through close visualization 7
• Full skin examination: Cannot be performed adequately via telehealth; patients at risk for melanoma require in-person visits 1

Vestibular/Oculomotor Assessment (for concussion or dizziness)

• Smooth pursuits: Have patient follow object slowly across visual field 6
• Saccades: Have patient rapidly shift gaze between two targets 6
• Vestibulo-ocular reflex: Guide patient through head movements while maintaining visual fixation 6
• Convergence: Assess near point of convergence by having patient follow object toward nose 6

Critical Limitations and Conversion Triggers

Examination Components That Cannot Be Performed Remotely:

• Palpation for masses, organomegaly, or subtle tenderness 2
• Auscultation without specialized peripheral devices 7
• Percussion 3
• Detailed joint examination requiring hands-on assessment 1
• Comprehensive skin examination 1

When to Convert to In-Person Visit:

• Physical examination findings are essential for diagnosis or management decisions 3, 1
• Patient has high-risk features (e.g., cardiovascular disease with respiratory symptoms) 2
• Suspected child abuse or situations requiring adolescent confidentiality assessment 3
• Need for laboratory confirmation or diagnostic procedures 3
• Unstable disease or acute flares requiring thorough examination 1

Enhanced Examination with Peripheral Devices

When available, peripheral devices significantly improve examination quality:

• Electronic stethoscopes for cardiac and pulmonary auscultation 2, 7
• Video otoscopes for ear examination 2, 7
• High-resolution cameras for detailed skin or wound assessment 2
• Home pulse oximeters and blood pressure monitors 2

Cost-benefit analysis should guide peripheral device purchases based on anticipated patient volume and clinical scenarios 2

Documentation Template Structure

Required Elements:

1. Consent for telehealth documented 2, 1
2. Technical platform used and any limitations encountered 4
3. Examination components performed with specific findings 1, 4
4. Examination components deferred due to telehealth limitations 3, 1
5. Plan for in-person follow-up if physical examination needed 3, 1
6. Patient education provided regarding self-examination techniques 1

Common Pitfalls to Avoid

• Do not rely solely on telehealth for conditions requiring hands-on examination, as this creates treatment shortcuts that compromise care 3
• Do not assume all patients have adequate technology or privacy; assess these factors at visit start 1
• Do not skip documentation of examination limitations; this is essential for medicolegal protection 3, 1
• Do not attempt full skin cancer screening via telehealth; these patients require in-person visits 1