Interagency Committee for Medical Records (ICMR); Documentation of Telemedicine

摘要

Based on the assumptions listed below, members of the Interagency Committee on Medical Records (ICMR) voted to approve the following guidelines which we recommend for adoption throughout the federal health care system: The Interagency Committee on Medical Records recommends a uniform approach to the documentation of telemedicine: the patient must provide written consent before an encounter is videotaped, there must be written documentation of the consultation by providers on both ends of the telemedicine encounter, and any permanent video images should be destroyed after written documentation is complete. The provider should indicate in his or her final documentation whether or not the image was destroyed. Exceptions to the prohibition against retaining videotapes may be permitted for cases with exceptional educational value. Any agency which chooses to keep images on file for educational purposes should have a standard operating procedure or policy on how the images will be maintained. This guideline should be reviewed periodically.