The demand for telemedicine increased markedly during the COVID-19 pandemic along with the clinician’s need to learn best practices with this technology. Although some aspects of in-office visits are amenable to telemedicine visits, performing a physical examination using telehealth technologies may be more challenging. As patients embrace the benefits of telehealth delivery in the home, health care providers must develop processes and strategies for in-home patient assessments. This 5-step guide will provide a process for conducting a primary care visit via videoconferencing with an adult patient in the home setting.
Step 1: Patient Preparation for a Telehealth Visit
A crucial step for maximizing the telehealth visit involves the provider strategically partnering with the patient to prepare for the visit. Table 1 summarizes important preparatory information.
Table 1. Preparation for Telehealth Visit
|Note the time of visit|
|Determine how the remote connection with the provider will be made|
|Determine the visit format: audio only or video|
|Provide an option to test equipment with a staff member prior to the visit|
|Recommend that the patient be located in a quiet, well-lit area free from distractions|
|Write down questions before the visit|
|Have medications available for review|
|Have blood pressure, pulse, weight, and other patient-specific measurements available|
Step 2: Tele-etiquette
After establishing a remote connection with the patient, determine whether they can hear you, confirm the patient’s identity, and obtain verbal consent for the telehealth visit. Briefly explain the privacy and confidentiality of the visit, any instances when confidentiality is required to be breached, and that the visit is not being recorded. Also, provide a contingency plan in the event the connection is lost. Additionally, identify any other person(s) present at the visit and their relationship to the patient. The provider should document all of the above steps in the visit note.
Providers should be dressed professionally. Unauthorized individuals should not be present at the provider’s site and the provider should silence phone and computer alerts. Position the camera so the provider is centered on the patient’s screen. The provider should maintain eye contact with the camera/patient. If the provider must look away to view a patient record on a computer screen, this should be explained to the patient.
The clinician should provide adequate privacy to protect the patient’s health information and the visit should be conducted through a Health Insurance Portability and Accountability Act of 1996 (HIPPA) compliant platform. The Department of Health and Human Services (HHS) Office for Civil Rights has temporarily waived penalties for HIPPA violations against health care providers who conduct telehealth visits through popular video technologies such as FaceTime, Facebook Messenger video chat, Zoom, or Skype. However, public platforms such as TikTok, Facebook Live, Twitch, and other similar video communications should not be used due to the lack of privacy.1
Step 3: Patient Assessment
Taking an adequate patient history is crucial as it drives the selection of physical examination assessments and the decision to continue the visit via telehealth or refer the patient to a medical facility for an in-person visit.
The telehealth visit is conducted in a manner similar to an office visit. The chief complaint, history of present illness (HPI), and review of systems (ROS) are easily obtainable via telehealth. Review and update the patient’s medical/family/social history and medication list as needed. The extent of the physical examination will depend on the platform utilized and the equipment available to the patient.2-5 If video is available, perform parts of the physical examination with the provider guiding the patient to move the camera close to various body areas for visualization (Table 2). If needed, instruct the patient to use light from a smartphone or flashlight to visualize areas such as the nasal passages and posterior pharynx.
Table 2. Example of Telehealth Physical Examination Using Video Conferencing
|Vital signs |
• Patients can check their temperature, blood pressure, weight, and pulse oximeter when equipment is available
• Patients can be taught to check pulse rate
• Have patient cross arms on chest for the provider to count respiratory rate
• Overall appearance (pallor, flushed, diaphoretic) and mood
• Visualize normocephalic and atraumatic
• Visualize conjunctiva with a close-up camera; eye movement can be assessed
• Examine if the patient has a digital otoscope and smartphone app
• Visualize internally with a close-up camera and patient shining a light
• Nasal flaring can be assessed
• Visualize inside the mouth and posterior pharynx by having the patient move close to the camera with mouth wide open
• Tongue position and movement can be assessed
|Lymph nodes |
• Patient can be taught self-palpation of the anterior and posterior cervical chains and the submandibular nodes to assess enlargement and tenderness
• Labored respirations can be visualized with use of accessory muscles
• Expiratory wheezes may be heard if the patient is asked to take a deep breath and forcefully exhale
• Characteristics of cough can be assessed
• Dyspnea with speech can be determined
• Breath sounds can be assessed with a digital stethoscope
• Assess heart sounds with a digital stethoscope
• Visualize abdomen using the camera
• Patient or family member can be instructed on areas to palpate to determine if pain present
• Child can be asked to jump up and down to determine the presence of appendicitis pain
• Joint range of motion, gait analysis, and bony deformities can be observed
• Cognition: assess thought processes, memory, and orientation
• Coordination: assess fine finger movements, rapid alternating movements, and finger-nose-finger
• Facial movements: assess raising eyebrows, closing eyes, and smiling
• Rashes can be visualized by the patient presenting the affected area to the camera
• Patient can be asked to press down on the lesion to determine whether blanching is present
• Photo of the rash can be taken
Patients often have common tools for conducting a physical examination available in the home setting, such as a thermometer, blood pressure monitor, pulse oximeter, glucometer, peak flow meter, and scale. A variety of more advanced digital tools are also available including at-home dermatoscopes, digital stethoscopes, single-lead electrocardiogram (ECG), smartwatches that monitor heart rhythm and oxygen saturation, hormone tracking systems, and otoscopes.