Name of the Procedure:

Telephone Evaluation and Management Service (Telephonic E/M, Telehealth E/M)

Summary

A telephone evaluation and management service is a consultation provided by a physician or other qualified health care professional over the phone. It's specifically for established patients, their parents, or guardians and is not related to a previous evaluation and management (E/M) service.

Purpose

This service addresses medical concerns or health questions that a patient or their caregiver has when an in-person visit isn't necessary or feasible.

Goals/Expected Outcomes:

• To provide immediate medical advice and management.
• To determine if an in-person visit or further testing is necessary.
• To offer continuity of care and timely intervention.

Indications

Symptoms/Conditions:

• Mild to moderate symptoms such as a sore throat, cough, minor injury, or rash.
• Management of chronic conditions (e.g., diabetes, hypertension).
• Follow-up on test results or treatment plans.

Patient Criteria:

• Established patients only.
• Situations where a visit to the office isn't required immediately.

Preparation

Pre-procedure Instructions:

• Be in a quiet and private location during the call.
• Have a list of symptoms, questions, and medications at hand.
• Ensure your phone is charged and has good reception.

Diagnostic Tests/Assessments:

• None usually required prior to the call unless specified by the healthcare provider.

Procedure Description

1. The healthcare provider will call the patient at the scheduled time.
2. Discuss symptoms, medical history, and any concerns.
3. The provider may offer medical advice, prescribe medication, or recommend further action.
4. Document the call and recommendations.

Tools/Equipment:

• Telephone or mobile phone.

Anesthesia/Sedation:

• Not applicable.

Duration

Typically 5-30 minutes depending on the complexity of the issue.

Setting

The patient's location via phone. The healthcare provider could be calling from any clinical setting like a hospital, clinic, or home office.

Personnel

• Physician or other qualified health care professional (e.g., nurse practitioner, physician assistant).

Risks and Complications

Common Risks:

• Miscommunication or misunderstandings over the phone.
• Limitations in assessing physical symptoms.

Rare Risks:

• Delay in diagnosis or treatment if the call is insufficient to address the issue appropriately.

Management:

• Follow-up with an in-person appointment or additional diagnostics if needed.

Benefits

• Quick access to medical advice.
• Convenience and comfort of being at home.
• Reduced need for travel and time off work/school.

Recovery

Post-procedure Care:

• Follow any instructions given during the call.
• Monitor symptoms and seek in-person care if necessary.

Expected Recovery Time:

• Immediate; no physical recovery needed.

Restrictions/Follow-Up:

• Depends on the advice given during the call.

Alternatives

Other Options:

• In-person consultation.
• Telehealth video consultation.
• Urgent care visit.

Pros and Cons of Alternatives:

• In-person visits allow for a physical exam, which can be more thorough.
• Video consultations provide visual assessment but require internet access.
• Urgent care visits are immediate but might be more costly and time-consuming.

Patient Experience

During the procedure, patients might experience:

• Feeling more at ease due to being in a familiar environment.
• Relief from receiving immediate professional advice.

Pain Management/Comfort Measures:

• Not applicable as this is a non-invasive service.

During and After:

• Expect clear communication and a personalized plan based on the discussion.