Documenting During COVID-19—What You Need to Know

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posted on Thursday, June 4, 2020

As an ND, it’s only natural to want to provide comprehensive health care to your patients. But this has been a challenge in some jurisdictions due to stay-at-home orders and generally with patients who are self-isolating to avoid catching the virus.  

Many NDs have been turning toward telemedicine and using the telephone to consult with patients outside of the normal practice setting. As well-intentioned and common as these efforts may be, they may result in incomplete documentation, putting the ND and their practice at risk.

Documenting the Nontraditional

Keep in mind that you should use the same standards for documenting clinical advice, continuity of treatment and informed consent discussions that you would use in your office. Patient interactions are supposed to be part of the chart, and in some states, they could be deemed to include electronic messaging, such as the aforementioned video, phone, IM (instant messaging) and text messages. If you are not uniform in which messages you keep and which ones you delete, it could also give rise to an argument that certain messages were intentionally deleted.

Additionally, HIPAA and state scope of practice requirements are at play, so make sure to maintain proper protocols and keep patient privacy paramount. Review HIPAA applications and make sure any platform you use is HIPAA compliant.

The use of personal text messages or emails may be allowed in specific instances, (such as an urgent “please go to the ER”), but generally these are not HIPAA compliant. During the virus crisis, the Department of Health and Human Services granted some flexibility in the choice of platforms, but not the use of any “outward facing platforms, ”(e.g., Facebook) that are not private.

Additionally, when you use written communications, such as a secure text or email, it is important to read the message carefully to avoid unintended meaning. In the absence of verbal and nonverbal (body language) cues, messages may be misperceived.

After a Gap in Care

As a result of COVID-19 restrictions, many of your regular patients may be returning after a gap in care.  With a new patient, you have certain protocols you follow. However, the issue can become a bit trickier if the patient has a lapse in care (e.g., due to COVID-19 restrictions).

Consider that things may have changed with the patient’s health, medications or other areas after a gap in care. Depending on how long it has been since you saw the patient, it may be advisable to follow new patient protocols. This may include:

  • Taking a complete history and performing a thorough examination of the patient’s subjective complaints. 
  • Assigning a working diagnosis to that patient’s condition.
  • Obtaining any physical data. Recognize if you’re using telemedicine, you’ll be limited by camera quality, practicality and the patient’s ability to describe the problem. (E.g., patient’s head is rotated 10 degrees to the right due to muscle spasm and tension.)
  • Developing a treatment plan and determining if you feel the patient would still respond to the treatment in which you are trained. If not, refer the patient to an appropriate specialist.
  • Obtaining the patient’s informed consent after discussing:
    • The nature of the treatment to be rendered
    • The material risks associated with the treatment and the possibility that those risks will occur
    • Alternative treatments available and their associated risks
    • The risks of not being treated
  • Properly documenting all of the above, as well as charting the patient’s complaints in the SOAP notes. Without a contemporaneously made record, there is no proof of anything—and make no mistake, people remember things differently, which could become an issue if there is a later concern about your care.

Beyond the Patient Encounter

Recent board complaints have alleged that some doctors are not adhering to the various jurisdictional pandemic guidelines. Thorough documentation relating to the practice’s administration may help in the doctor’s defense. This includes documenting any:

  • Staffing/duty changes
  • Changes in policies, procedures and advertising—and the rationale behind these decisions
  • Technical problems, such as computer crashes and power outages, and the need to use other devices as a result

Avoid Making and Documenting Inappropriate Claims and Goals

The Federal Trade Commission has sent warning letters to naturopathic physicians for implying they can treat or cure COVID-19. It’s important to be aware that the claim doesn’t have to be blatant—the mere mention of COVID-19 and natural products together may trigger a warning.

Therefore, be cautious not to overpromise treatment, and mirror the language you used in your records. For instance, if you recommend a nutritional treatment to support the patient’s normal immune function, it should be documented as such. There should be no room for interpretation that the treatment was suggested to “fight the coronavirus.”  

Both federal authorities and patients may take you to task if they interpret your advice as a guarantee of outcome or immunity. The American Association of Naturopathic Physicians has resources to assist in this good practice at and

Benefits for You—And Your Patients

Even with existing patients, it’s important to take all the necessary steps and to not let your guard down, especially during times of crisis. Your goal should be to provide the best clinical care and documentation possible. As a bonus, your patients will see you as a thorough and caring doctor—a doctor they’ll want to reward with their loyalty.

  1. coronavirous
  2. covid-19
  3. documentation
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