Telemedicine Physical Exam Template and Examples

Updated: April 25, 2024

Telemedicine offers a convenient service for patients and expands access to healthcare services. For many professionals (and patients), this is a new method of conducting a physical exam. Following a structured template ensures the exam is effective and patients’ needs are met during the remote session.

This article will guide you through creating an effective telemedicine physical exam, utilizing templates for streamlined documentation, and how TextExpander can help make the process smooth and easy.

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Crafting an Effective Telemedicine Physical Exam

Conducting virtual physical exams requires new skills to ensure comprehensive patient evaluation. When conducting a remote physical exam, here are some things to keep in mind:

  • Prepare your environment: Ensure that your setting is professional and that your technology functions correctly, with a good internet connection and camera quality.
  • Patient preparation: Instruct patients on what to expect during the exam and any necessary preparations for them to make, such as wearing appropriate clothing or being in a well-lit room.
  • Structured approach: Follow a systematic approach in your examination to ensure no aspect of the physical exam is overlooked. Inform the patient of your structure, and let them know how to ask questions throughout.

A physical exam template for telemedicine can guide you through the process, ensuring a thorough and consistent approach each time.

Benefits of Using a Telemedicine Physical Exam Template

Using a telemedicine physical exam template offers numerous benefits:

  • Consistency: Templates standardize the examination process, ensuring that every essential detail is consistently covered.
  • Efficiency: With templates, you can quickly document patient encounters without missing critical information, saving time and reducing errors.
  • Comprehensive documentation: A telemedicine physical exam documentation template helps in creating detailed patient records that are useful for follow-up visits and ongoing patient management.
  • Legal compliance: Accurate and thorough documentation assists in compliance with healthcare regulations and legal standards.

How TextExpander Can Help

TextExpander is a tool that can significantly boost productivity by allowing you to create shortcut keys for common phrases and paragraphs. With this, you can fill out your telemedicine physical exam template much faster. This reduces the typing required during each exam and minimizes the chance of missing key facts. TextExpander can be customized to include a variety of template responses, common data points, and medical codes, ensuring documentation is both swift and thorough.

Telemedicine Physical Exam Template and Examples

Telemedicine Physical Exam Template Copy Snippet Copied!

1. Patient Information:
Name:
Age:
Gender:
Date of Exam:

2. Medical History:
Chronic conditions:
Medications:
Allergies:

3. Symptoms Review:
Primary concern:
Symptom onset:
Severity and progression:

4. Visual/Physical Examination:
General appearance:
Specific areas of concern (documented with patient-provided images):
Notable findings:

5. Assessment and Plan:
Diagnosis (preliminary):
Recommended tests:
Treatment plan:
Follow-up:

Telemedicine Physical Exam Examples

Example 1: Hypertension Follow-Up

1. Patient Information:
Name: John Doe
Age: 58
Gender: Male
Date of Exam: April 23, 2024

2. Medical History:
Chronic conditions: Hypertension, Type 2 Diabetes
Medications: Metformin, Lisinopril
Allergies: None

3. Symptoms Review:
Primary concern: Blood pressure management
Symptom onset: N/A
Severity and progression: Concerns about increasing blood pressure readings

4. Visual/Physical Examination:
General appearance: Appears well-groomed, alert, and oriented
Specific areas of concern: None
Notable findings: Blood pressure reading provided via home monitor, 150/95 mmHg

5. Assessment and Plan:
Diagnosis (preliminary): Uncontrolled hypertension
Recommended tests: None additional at this time
Treatment plan: Increase Lisinopril dose, initiate daily blood pressure log
Follow-up: Virtual check-in in 2 weeks

Example 2: Acute Back Pain

1. Patient Information:
Name: Emily Tran
Age: 35
Gender: Female
Date of Exam: April 23, 2024

2. Medical History:
Chronic conditions: None
Medications: Ibuprofen as needed
Allergies: Penicillin

3. Symptoms Review:
Primary concern: Lower back pain after lifting heavy object
Symptom onset: Three days ago
Severity and progression: Pain is moderate, worsening with movement

4. Visual/Physical Examination:
General appearance: Appears uncomfortable, mild distress
Specific areas of concern: Lower back
Notable findings: Patient provided images of back showing no visible bruising or deformity

5. Assessment and Plan:
Diagnosis (preliminary): Muscle strain
Recommended tests: None
Treatment plan: Rest, ice, continued use of ibuprofen, and gentle stretches
Follow-up: Follow-up if no improvement in one week or if symptoms worsen

Example 3: Seasonal Allergies

1. Patient Information:
Name: Marcus Lee
Age: 29
Gender: Male
Date of Exam: April 23, 2024

2. Medical History:
Chronic conditions: Seasonal rhinitis
Medications: None
Allergies: Pollen

3. Symptoms Review:
Primary concern: Recurrent sneezing and nasal congestion
Symptom onset: Started last week
Severity and progression: Symptoms are mild but annoying, occur annually at this time

4. Visual/Physical Examination:
General appearance: Appears in no acute distress
Specific areas of concern: Nasal mucosa
Notable findings: Reddened nasal mucosa observed via transmitted images

5. Assessment and Plan:
Diagnosis (preliminary): Seasonal allergic rhinitis
Recommended tests: None
Treatment plan: Initiate over-the-counter cetirizine, nasal saline rinses
Follow-up: Return prn or if symptoms escalate to include sinus pain

What is TextExpander

With TextExpander, you can store and quickly expand full email templates, Slack messages, and more anywhere you type. That means no more misspellings, no need to memorize complex instructions, or type the same things over and over again. See for yourself here:

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With TextExpander, you can store and quickly expand full email templates, email addresses, and more anywhere you type. That means you’ll never have to misspell, memorize, or type the same things over and over again.

1. Patient Information: <br>Name: <br>Age: <br>Gender: <br>Date of Exam: <br> <br>2. Medical History: <br>Chronic conditions: <br>Medications: <br>Allergies: <br> <br>3. Symptoms Review: <br>Primary concern: <br>Symptom onset: <br>Severity and progression: <br> <br>4. Visual/Physical Examination: <br>General appearance: <br>Specific areas of concern (documented with patient-provided images): <br>Notable findings: <br> <br>5. Assessment and Plan: <br>Diagnosis (preliminary): <br>Recommended tests: <br>Treatment plan: <br>Follow-up:
1. Patient Information: <br>Name: John Doe <br>Age: 58 <br>Gender: Male <br>Date of Exam: April 23, 2024 <br> <br>2. Medical History: <br>Chronic conditions: Hypertension, Type 2 Diabetes <br>Medications: Metformin, Lisinopril <br>Allergies: None <br> <br>3. Symptoms Review: <br>Primary concern: Blood pressure management <br>Symptom onset: N/A <br>Severity and progression: Concerns about increasing blood pressure readings <br> <br>4. Visual/Physical Examination: <br>General appearance: Appears well-groomed, alert, and oriented <br>Specific areas of concern: None <br>Notable findings: Blood pressure reading provided via home monitor, 150/95 mmHg <br> <br>5. Assessment and Plan: <br>Diagnosis (preliminary): Uncontrolled hypertension <br>Recommended tests: None additional at this time <br>Treatment plan: Increase Lisinopril dose, initiate daily blood pressure log <br>Follow-up: Virtual check-in in 2 weeks
1. Patient Information: <br>Name: Emily Tran <br>Age: 35 <br>Gender: Female <br>Date of Exam: April 23, 2024 <br> <br>2. Medical History: <br>Chronic conditions: None <br>Medications: Ibuprofen as needed <br>Allergies: Penicillin <br> <br>3. Symptoms Review: <br>Primary concern: Lower back pain after lifting heavy object <br>Symptom onset: Three days ago <br>Severity and progression: Pain is moderate, worsening with movement <br> <br>4. Visual/Physical Examination: <br>General appearance: Appears uncomfortable, mild distress <br>Specific areas of concern: Lower back <br>Notable findings: Patient provided images of back showing no visible bruising or deformity <br> <br>5. Assessment and Plan: <br>Diagnosis (preliminary): Muscle strain <br>Recommended tests: None <br>Treatment plan: Rest, ice, continued use of ibuprofen, and gentle stretches <br>Follow-up: Follow-up if no improvement in one week or if symptoms worsen
1. Patient Information: <br>Name: Marcus Lee <br>Age: 29 <br>Gender: Male <br>Date of Exam: April 23, 2024 <br> <br>2. Medical History: <br>Chronic conditions: Seasonal rhinitis <br>Medications: None <br>Allergies: Pollen <br> <br>3. Symptoms Review: <br>Primary concern: Recurrent sneezing and nasal congestion <br>Symptom onset: Started last week <br>Severity and progression: Symptoms are mild but annoying, occur annually at this time <br> <br>4. Visual/Physical Examination: <br>General appearance: Appears in no acute distress <br>Specific areas of concern: Nasal mucosa <br>Notable findings: Reddened nasal mucosa observed via transmitted images <br> <br>5. Assessment and Plan: <br>Diagnosis (preliminary): Seasonal allergic rhinitis <br>Recommended tests: None <br>Treatment plan: Initiate over-the-counter cetirizine, nasal saline rinses <br>Follow-up: Return prn or if symptoms escalate to include sinus pain

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