Document the telemedicine encounter in EMR (consent, limitations, assessment, plan).

You complete the telemedicine documentation in Ny. M’s EMR, including:

• verification of her identity and current location,
• consent for the telemedicine consultation and who was present,
• relevant history, including the sudden onset of right-sided weakness, difficulty speaking, dizziness, and the approximate time of symptom onset,
• relevant medical history, including uncontrolled hypertension,
• findings from the remotely guided neurological assessment,
• limitations of the virtual examination and any connection problems,
• your assessment that the findings are concerning for an acute neurological event,
• the recommendation for immediate assessment at the emergency department,
• the referral and safety-netting instructions communicated to Ny. M and her daughter.

The documentation provides a clear record of what was assessed remotely, how the findings were interpreted, and why urgent referral was recommended.