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PATIENT CONSENT - TELEMEDICINE ONLY
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Patient Consent
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Patient consent given for telemedicine by:
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Vitals Obtained
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Start Time
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End Time
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LABOR AND DELIVERY
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Baby's Date of Birth (MM/DD/YYYY):
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Baby's Name:
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Baby's Sex
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Baby's Weight (lbs/oz):
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Mode of Delivery:
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Length of Labor (hours):
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Gestational Age
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Maternal Postpartum Issues:
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Did patient had multiple births?
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Multiple Birth Type:
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Did you have any complications during your pregnancy/delivery?
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Describe Complications:
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NEONATAL
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Does infant have a pediatrician?
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Pediatrician Name:
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Has infant had a newborn check-up?
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What are you feeding your baby?
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Other Feeding Issues:
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How many wet diapers does your baby have per day?
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Did you infant have complications:
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Do you have any of the following concerns?
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Other Neonatal Issues:
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PSYCHOSOCIAL
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1. Does the baby have any medical issues?
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If yes, describe:
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2. Do you Have any emotional, social or financial concerns?
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If yes, describe:
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4. Are you getting the support you need from family/partner?
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If no, describe:
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3. Are family members adjusting to the baby?
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If no, describe:
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5. Do you drink alcohol?
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If yes, please select guidance:
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6. Do you use drugs other than prescribed?
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If yes, please select guidance:
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7. Do you smoke (includes e-cigarettes)?
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If yes, please select guidance:
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8. Within the last year, has your partner hit, kick, slap, force sex, or other physically/emotionally hurt you?
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Mandated Reporting Completed Date (MM/DD/YYYY):
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If yes, please select guidance:
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9. What are your plans for the future?
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10. Do you need help finding childcare?
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If yes, describe:
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11. Do you need essential baby supplies (diapers, formula, etc.)?
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If yes, please select guidance:
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12. Are you currently using birth control?
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If no, please select guidance:
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13. Would you like to become pregnant within next 18 months?
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If no, please select guidance:
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14. How many hours of sleep are you getting?
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15. Are you able to sleep when your baby is sleeping?
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16. Are you able to sleep when someone else is taking care of the baby?
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17. Has a doctor told you that you have any health issues that need follow up? (diabetes, hypertension, obesity, depression?
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If yes, describe:
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DEPRESSION SCREENING (PHQ2/PHQ9)
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1. Have you had any emotional concerns that need follow-up?
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If yes, describe:
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PHQ2
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1. In the past 2 weeks, have you often been bothered by having little interest in doing things?
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2. In the past month, have you often been bothered by feeling down, depressed, or hopeless?
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Depression Screening Completed (defaulted to ON, CPT2 Code)
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If patient answers yes to either question, tap on PHQ9 button.
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PHQ-9
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1. Little interest or pleasure in doing things
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2. Feeling down, depressed, or hopeless
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3. Trouble falling or staying asleep, or sleeping too much
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4. Feeling tired or having little energy
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5. Poor appetite or overeating
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6. Feeling bad about yourself or that you have let yourself or family down
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7. Trouble concentrating on things, such as reading the newspaper or watching TV
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8. Moving or speaking so slowly that other people could notice or being fidgety or restless
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9. Thoughts that you would be better off dead, or of hurting yourself
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Does the patient have at least 5 of the 9 symptoms above?
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TOTAL PHQ-9 SCORE
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Depression Severity Results
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Add numbers in ( ) for PHQ9 Total Score
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EXAM / ASSESSMENT
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BREAST
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Abnormal
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ABDOMEN/PELVIS
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Abnormal
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PSYCH
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Abnormal
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ADDITIONAL COMMENTS RE EXAM
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ASSESSMENT & PLAN
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Postpartum Dx (drops Dx and CPT2)
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1. Assessment & Plan
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2. Assessment & Plan
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3. Assessment & Plan
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5. Assessment & Plan
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REFERRALS / CONCERNED PT ENCOUNTER
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TURN ON for Referrals & Concerned Pt. Encounter
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Notes to PCP:
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