Send instructions only via chat and skip detailed EMR note.

You send Ny. M’s daughter a brief message with instructions to take her mother to the emergency department, but you leave only a minimal note in the EMR.

The record does not clearly document the time of symptom onset, the neurological findings observed during the video consultation, the limitations of the remote assessment, your clinical reasoning, or the referral and safety-netting discussion.

When Ny. M arrives at the emergency department, the receiving team cannot easily reconstruct what happened during the telemedicine consultation or why the referral was considered urgent.

You realize that in telemedicine, documentation is part of communication and continuity of care.