TELEMEDICINE POLICIES AND PROCEDURES

 

PURPOSE:
To ensure adherence to all applicable laws, rules, and regulations while ensuring patient access to 
Psychiatry through the use of “live two-way audio-visual communication”. By implementing these 
procedures, (Completely Centered Health, LLC) will provide “long distance” medical services to 
patients.
PROCEDURES:
I.          DEFINITIONS
(Telepsychiatry ) - Telepsychiatry, also called telehealth mental health or teletherapy, can 
involve direct interactions that is done through a HIPPA compliant video chatting platform, or 
other means such as, talking, between patients and psychiatrists, as well as psychiatrists 
supporting primary care providers with mental health consultations and expertise.

Telemedicine - The use of electronic communication and information technologies to provide or 
support medical care at a distance.  This definition includes: (1) live interactive two-way audio- 
video communication; and (2) any communication modalities such as phone, fax, e-mail, the internet, 
and still imaging that are used in conjunction with such live two-way audio-video communication.  
The same standards of care and protocol exist with telemedicine as are used when assessing and 
treating the patient on-site.  The provider-patient relationship is the same.
Even though an “in person” examination is not performed, a physical inspection is performed 
utilizing the video chat and a thorough history, assessment, plan and laboratory evaluation is 
performed thus establishing a provider-patient relationship.

Medical Providers/Providers – A licensed MD, DO, NP, or PA.

 

II.        APPLICATIONS/SCOPE
A.        Services
1.   The following services will be available through the use of telemedicine:
•    Psychiatric Evaluation Initial assessment
•    Medication Management
•    Psychotherapy

2.   Treatment via telemedicine will not deviate from standards of care applicable to face- to- 
face assessment and treatment.

3.   The telemedicine (telepsychiatry) by the medical provider may be an adjunct to periodic 
face-to-face contact or it may be the only contact by the medical provider if medical provider 
deems it unnecessary to have an in-person evaluation.
B.  Locations
Telepsychiatry medical services will be provided as follows:


1.   Patient at remote location/Provider at remote location – Medical provider will be at a 
location of their choosing operating under Completely Centered Health, LLC and the patient will be 
at a location of their choosing such as their home.

C.  Clinical Oversight
Clinical oversight of telepsychiatry medical care will be provided by random audits of patient 
charts by the Completely Centered Health clinical directors.

Medical providers will have access to clinical directors for clinical questions as they arise.

D.  Contraindications for Use
The consulting provider should request face-to-face consultation if the patient's condition does 
not lend itself to a telemedicine consultation or if visual or sound quality is inadequate.

IV.       PRIVACY, CONFIDENTIALITY AND SECURITY
A.  The privacy and confidentiality of the telemedicine medical service will be maintained by 
ensuring that the locations of the patient and medical provider are secure. The services will be 
provided in a controlled environment (closed doors) where there is a reasonable expectation of 
absence from intrusion by individuals not involved in the patient's direct care.
B.  “Do Not Enter” signs will be recommended to be posted on the outside doors of facilities used 
in order to notify individuals not to enter the room during the telemedicine visit.
C.  Completely Centered Health, LLC staff, or ancillary contracted staff, involved in the patient’s 
care, family members and technical staff may at times be present in interviews. Patients will be 
informed about others present in the room at the distant site if such persons are off camera and 
appropriate authorizations for disclosure of information will be obtained.  Whenever possible, the 
presence of non-clinical staff during the telemedicine visit will be avoided.
D.  The telemedicine medical service will not be audio- or video-taped without written informed 
consent from the patient.

V.        INFORMED CONSENT
A.  Informed consent for telepsychiatry and telemedicine services will be obtained from the patient 
prior to the service.

B.  The patient will be made aware of the potential risks and consequences as well as the likely 
benefits of the telemedicine, telepsychiatry services and will be given the option of not 
participating. If patients choose to not participate in care provided by (Completely Centered 
Health, LLC), the provider will refer the individual to (PCP OR SPECIALIST) for further management.

C.  The content of the consent will be discussed fully, and a note documented in the record that 
this has occurred.


D.  The original signed consent will be filed in the patient’s medical record.


VI.       REQUIRED DOCUMENTATION
A.  All documentation of medical services will be documented in accordance with applicable 
standards, guidelines, by-laws, rules and regulations. Providers will be expected to document in 
the provided cloud based EMR.

B.  A Progress Note will be completed by the medical provider to document each visit with the 
patient.  The progress will be completed within 24 hours of the visit.

C.  Upon admission to (Completely Centered Health, LLC ), an initial visit will be conducted by the 
medical provider and documented in the patient’s record.

D.  Prescriptions will be documented within the EMR for each patient every time a prescription is 
issued.

E.   Orders for lab work and notation of review of lab work will be documented in the progress 
notes.

F.   When equipment failure prevents adequate diagnosis or treatment, a progress note should be 
written to document such failure and later transcribed into the EMR.

VII.     MEDICAL RECORDS
A.  Medical records will be saved in the cloud based EMR and are available/accessible for routine 
care and in emergency situations.


VIII.    EQUIPMENT FOR VIDEOCONFERENCING
A.  All medical providers will be expected to have a personal computer, laptop, or tablet that is 
capable of video conferencing and for operating the EMR.

X.        SPECIFIC OPERATING PROCEDURES AND EXPECTATIONS
A.  Scheduling of appointments for medical services will be predominately performed online through 
the cloud based EMR scheduling portal accessed from the website. Patients will select the medical 
provider based off available open times and create an appointment. If a patient calls requesting an 
appointment, they will be directed to the online portal and will make the appointment themselves.

B.  Completely Centered Health, LLC answering service will respond within 24 hours to your needs. 
This answering service will be responsible for answering patient’s basic questions, coordinating 
scheduling, and referring to medical providers as necessary.

XI.       PROVIDER RESPONSIBILITIES
A.  Provider will be responsible for answering clinically relevant questions, concerns or 
urgent/emergent matters that patient needs. Provider will be responsible to address these

matters for the patients they provide care too. It will be expected that the matter will be 
addressed within 2 hours of notification. Provider is responsible for this during the hours of 8am 
- 9PM. Provider should anticipate this happening very sparingly as telepsychiatry is well tolerated 
by most patients.

B.  Provider will be responsible for ordering labs through the (Access Lab) portal at the end of 
the patient encounter. Provider is responsible for entering in the patient’s demographic data into 
this lab portal and initiate the order. After the order is placed into the (Access Lab) portal, 
provider must also input the lab charge into the EMR.


C.  Provider is responsible for reviewing the patient’s lab work prior to the initiation of the 
follow up visit. It is the clinical director’s responsibility to address critical values that the 
lab will call into (Access Lab).

D.   Prescriptions will be called in or eRx by the provider.

1.   It is the providers responsibility to ensure they follow lawful prescribing of controlled 
substances. It is the providers responsibility to coordinate an in-person evaluation prior to the 
prescription of a controlled substance. Prescriptions for a controlled substance should not exceed 
the amount permitted by law.

F.   Scheduling
1.   During this initial consultation it is the providers responsibility to ensure the informed 
consent is reviewed, absolute and relative contraindications are assessed and a completely history 
is performed.
2.   After the initial consultation, lab work will be ordered and the follow up visit will be 
scheduled in 2-4 weeks. This follow up visit is when lab work will be reviewed, and a plan will be 
started.

G.  It is the provider’s responsibility to stay up to date in current medical practices regarding 
psychiatry.

H.  It is the provider’s responsibility to educate the patient about the importance of 
establishing, following up and maintaining care with a primary care provider outside of services 
provided by Completely Centered Health, LLC.

I.    It is at the provider’s discretion to obtain a full physical examination of the patient prior 
to initiating treatment. An inspection examination will be performed during the initial video 
visit. A physical exam can be done by the patients primary care provider or at an urgent care and 
sent to Completely Centered Health, LLC.


I acknowledge that I have received a copy of the above policies and procedures, which describes 
important information about Completely Centered Health, LLC, and understand that I should consult 
the Completely Centered Health, LLC administrators and/or directors if I have questions.

Since the information, policies and procedures described here are necessarily subject to change, I 
acknowledge that revisions to the policies may occur. I understand that (Completely Centered 
Health, LLC) may change, modify, suspend, interpret or cancel, in whole or part, any of the 
published or unpublished personnel policies or practices, with or without notice, at its sole 
discretion. Such revised information may supersede, modify or eliminate existing policies.
Completely Centered Health, LLC shall have sole authority to add, delete or adopt revisions to 
these policies and procedures. Any oral statement by administration or an employee of Completely 
Centered Health, LLC contrary to these policies and procedures is invalid.

I understand and a  ree that I will read and comply with the policies contained in this document
and any revisions.