Documentation During Visits

During a telemedicine visit, you can document comprehensive patient information including symptoms, progress notes, vitals, and medical history. CureCompanion provides structured forms and tools to help you capture all necessary clinical information efficiently.

Starting Point: Minimizing the Video Call

When you’re in an active video call with a patient, you’ll need to minimize the video call to access the documentation tools:

1. During the video call, look for the minimize icon in the video controls navigation bar
2. Click the “Minimize video” button (resize icon) to minimize the video window
3. The system will redirect you to the visit details page while keeping the call active
4. The video call continues in a minimized state, allowing you to document while maintaining the consultation

Adding Symptoms

You can record patient symptoms during or after the visit to maintain accurate clinical documentation.

To add symptoms:

1. Navigate to the symptoms section in the visit documentation area
2. Click the “Add Symptom” button
3. Enter the symptom description in the text field
4. Specify additional details such as:
   • Onset and duration
   • Severity level (Mild, Moderate, Severe)
   • Associated factors
   • Optional description field for additional details
5. Click “Add” to add the symptom to the visit record

You can add multiple symptoms for a single visit. Each symptom entry will be saved separately and can be edited or removed if needed.

Progress Notes Using the SOAP Format

CureCompanion supports the standard SOAP (Subjective, Objective, Assessment, Plan) format for clinical documentation, helping you maintain structured and comprehensive progress notes.

Subjective Section

Document the patient’s reported symptoms, concerns, and subjective experience:

1. Click in the “Subjective” section of the progress notes
2. Record patient complaints in their own words
3. Include relevant history of present illness
4. Note any patient concerns or questions
5. Document review of systems findings

Objective Section

Record your clinical observations and measurable findings:

1. Navigate to the “Objective” section
2. Document vital signs and measurements
3. Record physical examination findings
4. Include any diagnostic test results
5. Note clinical observations and assessments

Assessment Section

Provide your clinical assessment and diagnosis:

1. Enter your clinical impression in the “Assessment” section
2. List primary and secondary diagnoses
3. Include differential diagnoses when appropriate
4. Note any changes from previous assessments
5. Document diagnostic reasoning

Plan Section

Outline your treatment plan and recommendations:

1. Document treatment recommendations in the “Plan” section
2. Include medication prescriptions and dosages
3. Specify follow-up instructions
4. Add patient education points
5. Schedule any necessary follow-up appointments

Editing and Saving Progress Notes

You can edit progress notes throughout and after the visit to ensure accurate documentation.

To edit progress notes:

1. Click in any section of the SOAP notes to begin editing
2. Use the rich text editor features to format your documentation
3. Make changes to any section as needed during the visit
4. Click “Save” to preserve your changes
5. Continue editing other sections as required

The system requires manual saving using the “Save” button located below the progress notes editor. While the interface shows AI-generated content warnings, there does not appear to be automatic saving functionality, making manual saving critical to preserve your documentation work.

Rich Text Editor Features

CureCompanion’s rich text editor provides formatting options to create professional clinical documentation.

Available formatting features include:

• Bold and italic text for emphasis
• Bullet points and numbered lists for structured information
• Font size options for highlighting important information
• Hyperlink insertion for references
• Undo and redo functionality
• Copy and paste support for efficient documentation

To use formatting features:

1. Select the text you want to format
2. Choose the desired formatting option from the toolbar
3. The formatting will be applied immediately
4. Continue typing to maintain the formatting style

Review of Systems

The review of systems section allows you to document systematic inquiry about symptoms across all body systems.

To complete the review of systems:

1. Navigate to the “Review of Systems” section in the visit documentation
2. Select each organ system category (cardiovascular, respiratory, neurological, etc.)
3. Mark symptoms as needed
4. Save your review of systems documentation

The complete list of organ system categories includes:

• General (Unexplained weight loss/gain, fever, chills, fatigue)
• Respiratory (Cough, shortness of breath, runny nose, hemoptysis, chest pain)
• Neurological (Headache, memory loss, fainting, dizziness, numbness/tingling, frequent falls)
• Skin (Rash, sores, discoloration, yellow skin, dry skin, pale skin, itching)
• Gastrointestinal (Heartburn/reflux/indigestion, bloody stools, diarrhea, constipation, vomiting, nausea)
• Psychiatric (Anxiety, stress, irritability, sleep problems, lack of concentration)
• Ears/Nose/Throat (Nosebleeds, trouble swallowing, frequent sore throat, hearing loss, ringing in ears)
• Eyes (Change in vision, eye pain, redness)
• Hematological/Lymphatic (Swollen glands, painful glands, easy bruising)
• Musculoskeletal (Neck pain, back pain, muscle/joint pain)
• Cardiovascular (Chest pain/discomfort, palpitations)

Recording Vitals and Diagnostics

Document patient vital signs and diagnostic information to maintain comprehensive clinical records.

Recording Vital Signs

To record vital signs:

1. Expand the Vitals and Diagnostics section of the visit page.
2. Click on the + icon.
3. Select Vitals Signs from the list of diagnostics:
   
   
4. Enter measurements in the appropriate fields:
   • Blood pressure (systolic/diastolic)
   • Heart rate (beats per minute)
   • Temperature (Fahrenheit or Celsius)
   • Respiratory rate (breaths per minute)
   • SpO2 (oxygen saturation percentage)
   • Weight (in pounds)
   • Height (in inches)
   • Date and time of measurement
5. Specify the date/time the vitals were taken
6. Save the vital signs data

Recording Diagnostics

For diagnostic information:

1. Access the “Diagnostics” section
2. Enter diagnostic test results:
   • Laboratory values with reference ranges
   • Imaging study results and interpretations
   • Diagnostic procedure outcomes and findings
   • Results are organized by date for tracking changes over time
3. Include reference ranges when applicable
4. Add interpretation notes
5. Save the diagnostic information

Documenting Medical History

Maintain comprehensive medical history documentation for ongoing patient care.

Medical Conditions

To document medical conditions:

1. Navigate to the “Medical Conditions” section
2. Click “Add Condition” to enter new medical problems
3. Specify:
   • Condition name or ICD code
   • Date of diagnosis
   • Current status (active, resolved, chronic)
   • Treating provider information
   • Additional notes for context or details
4. Save each condition entry

Allergies

Document patient allergies and adverse reactions:

1. Access the “Allergies” section
2. Click “Add Allergy” to enter new allergy information
3. Record:
   • Allergen name
   • Reaction type and severity
   • Date of first reaction
   • Management notes
4. Save allergy information

Current Medications

Maintain accurate medication lists:

1. Go to the “Medications” section
2. Click “Add Medication” for new entries
3. Include:
   • Medication name and strength
   • Dosage and frequency
   • Prescribing provider
   • Start date
   • Indication for use
4. Update medication status as needed (active, discontinued, held)

Surgical History

Document surgical procedures and interventions:

1. Navigate to the “Surgical History” section
2. Add surgical procedures with:
   • Procedure name
   • Date performed
   • Surgeon and facility
   • Complications (if any)
   • Recovery notes
3. Save surgical history entries

Family History

Record relevant family medical history:

1. Access the “Family History” section
2. Document family member medical conditions:
   • Relationship to patient
   • Medical condition
   • Age of onset
   • Current status
3. Note patterns of hereditary conditions

Social History

Document social factors affecting patient health:

1. Navigate to the “Social History” section
2. Record relevant social information using frequency scales (Never/Sometimes/Frequently):
   • Smoking and tobacco use
   • Alcohol consumption
   • Drug use history
   • Exercise habits
   • Diet and healthy eating patterns
3. Update social history as circumstances change

Tips for Efficient Documentation

• Use templates and shortcuts when available for common documentation patterns
• Document during the visit when possible to ensure accuracy and completeness
• Review all sections before finalizing the visit to ensure nothing is missed
• Save frequently to prevent loss of documentation work
• Use structured formats like SOAP notes for consistent professional documentation

Additional efficiency features available:

• AI-generated progress notes with transcription from visit recordings
• Structured checkbox interfaces for Review of Systems to speed data entry
• Dropdown menus for standardized entries (severity levels, frequencies)
• Rich text formatting toolbar for professional documentation appearance
• Collapsible sections to focus on specific documentation areas
• Pre-filled patient demographics and previous visit data for reference

Remember that thorough documentation not only supports quality patient care but also meets regulatory and legal requirements for telemedicine visits.