Name of the Procedure:

Telephone Evaluation and Management Service
Common Names: Telephone consult, Telehealth evaluation

Summary

A telephone evaluation and management service involves a healthcare professional evaluating and providing management advice to an established patient, parent, or guardian over the phone. This remote consultation aims to address health issues without requiring a physical visit.

Purpose

Medical Conditions Addressed:

• Routine follow-up on chronic conditions
• Minor acute issues that can be managed remotely
• Monitoring and advice for ongoing treatments

Goals and Expected Outcomes:

• Convenient and timely medical advice
• Effective management of minor health concerns
• Reduced need for in-person visits
• Improved accessibility to healthcare

Indications

Symptoms or Conditions Warranting the Procedure:

• Mild symptoms such as cold, flu, minor injuries
• Chronic disease management (e.g., diabetes, hypertension)
• Medication management or adjustments
• Follow-up after a prior in-person visit

Patient Criteria:

• Established relationship with the healthcare provider
• Non-emergency health concerns

Preparation

Pre-procedure Instructions:

• Have medical history and current medication list available
• Be prepared to describe symptoms clearly

Diagnostic Tests or Assessments:

• May require prior diagnostic results, but not typically necessary

Procedure Description

1. Scheduling: The patient schedules a telephone consultation.
2. Initial Contact: The healthcare professional calls at the designated time.
3. Health Evaluation:
   • Review of symptoms and medical history
   • Discussion of current health status
4. Management Plan:
   • Provide medical advice
   • Adjust medications if necessary
   • Discuss follow-up actions or referrals if needed
5. Documentation: The healthcare professional documents the interaction in the patient’s medical record.

Tools, Equipment, Technology:

• Telephone

Anesthesia or Sedation:

• Not applicable

Duration

Typically lasts 10-30 minutes, depending on the complexity of the patient's needs.

Setting

Conducted via telephone, typically while the healthcare professional is in a private, confidential setting like an office or home office.

Personnel

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

Risks and Complications

Risks:

• Miscommunication due to lack of physical examination
• Potential for missing a more serious condition

Complications:

• Misdiagnosis or delayed diagnosis if symptoms are not accurately described

Benefits

• Increased convenience and accessibility
• Reduced need for travel
• Quicker access to healthcare advice
• Continuity of care

Recovery

Post-Procedure Care:

• Follow any advice or medication adjustments provided
• Schedule follow-up appointments if necessary

Expected Recovery Time:

• Immediate advice provided, no physical recovery needed

Restrictions:

• Follow any specific instructions given during the call

Alternatives

Other Treatment Options:

• In-person visits to a clinic or hospital
• Video telehealth consultations

Pros and Cons:

• In-Person Visits: Provide a more thorough evaluation but require travel and time.
• Video Consultations: Offer visual assessment capabilities but need internet access and technology.

Patient Experience

During Procedure:

• Expect a thorough discussion of your health concerns.
• Be prepared to answer questions about your symptoms and medical history.

After Procedure:

• Immediate access to medical advice.
• Minimal to no discomfort or pain associated with the procedure.
• Follow instructions for any further care or medication adjustments.