HTF 402 National First Nations Telehealth Research Project
 (57
K)
Attachment 2: Patient Encounter Forms
FIRST NATIONS TELEHEALTH PROJECT: La Romaine
- PATIENT CODE, DATE OF VISIT,
Person who completed the form, Time use of telehealth system began, Time use of telehealth system ended
- WHAT IS THE PURPOSE OF THE PATIENT'S VISIT TO THE HEALTH CENTRE?
- urgent problem
- medical or surgical follow-up or medication check
- health problem
- routine preventive examination
- other
- WHY WAS THE TELEHEALTH SYSTEM USED?
- confirmation of diagnosis
- justification of a transfer
- routine follow-up
- case management without transfer
- request for appointment
- Was there a previous meeting using the telehealth system?
If so, when?
- other reason (specify)
- THE TELEHEALTH DATA WERE TRANSFERRED BY:
- nurse (name)
- technician (name)
- physician (name)
- patient
- other
- WHO RECEIVED THE DATA FROM THE TELEHEALTH SYSTEM REMOTE SITE?
- nurse family physician
- medical specialist (what specialty?)
- other?
- at which site(s)?
- If the telehealth service was not available, what would happen with this patient today?
- No service
- Wait for visit to La Romaine by the physician/specialist
- Transfer of patient
- Other
- WHAT IS TO BE DONE NOW?
- No further action is required
- Follow-up is required
- Other
- The patient is to be transferred
- The patient is to be seen again by the telehealth service
- WHY WAS THE TELEHEALTH SYSTEM USED?
- Data transferred by the patient (user of a blood glucose monitor)
- System used during a visit to the health centre. Specify the reason
- ECG. Specify the reason
- Specific examination
- ears
- nose
- throat
- mouth
- other:
- Specify
- DID ANY LOGISTICAL OR CO-ORDINATION PROBLEMS ARISE IN THE USE OF TELEHEALTH?
- No
- Yes. Specify the reason
- DID ANY PROBLEMS ARISE IN CONNECTION WITH:
- the operation of the equipment?
- the recording and storing of data?
- interpretation by the staff at the remote site?
- access to the telehealth system?
- transmission time?
- data transmission?
- image quality?
- Other
- ADDITIONAL INFORMATION ON THE PATIENT
- PLEASE FAX THE DULY COMPLETED FORM TO 514-398-1531.
If you have any questions, call 514-398-3247.
SOUTHEND TELEHEALTH SESSION FORM FAX TO: 514-398-1531
DATE OF VISIT, TIME SESSION BEGAN, Time telehealth system disconnected,
PERSON COMPLETING FORM, Time telehealth system connected, TIME
SESSION ENDED
- WHY WAS THE TELEHEALTH SYSTEM USED?
- Patient care: FILL IN BOX 1
- Patient education: FILL IN BOX 2
- Staff/community education or development : FILL IN BOX
3
- 0ther: WRITE DETAILS ON BACK OF FORM
- BOX 1: PATIENT CARE
- PATIENT CODE
- non-urgent health problem
- Who was there at the telehealth session? In Southend
- Patient, Health centre nurse, CHR, Mental health worker,
Physician, Translator, Family Member, Other
- Other site: where?
- Family physician, Psychologist, Specialist Type, Nurse,
Health educator, Social worker, counselor, Translator, Family
Member, Other
- What was done during the session?
- Specialist consult
- to discuss or confirm diagnosis, to follow up on previous,
to discuss case management, Other
- Other patient care: describe
- What will happen next?
- No further action is required
- Follow-up is required
- with telehealth, without telehealth
- Patient is to be transferred to, Other, Did this session
result in avoiding a patient transfer? (Yes/No/Maybe)
- BOX 2: PATIENT EDUCATION
- individual OR group session, how many attended? Where?
Telehealth office OR Mental health room
- What was done during the session?
- Diabetes education, what topics?
- Diet/nutrition, Smoking, Insulin, Foot care, Hypertension
- Exercise, Alcohol, Glucose monitoring, Counseling or
support, Other
- Other patient education , what topics?
- BOX 3: STAFF/COMMUNITY EDUCATION OR DEVELOPMENT
- Who was there at the telehealth session?
- In Southend, Other site: where?
- Staff : how many?, Community members: how many?,
Translator, Other
- Psychologist, Diabetes educator, Other educator,
Nurse, Social worker, counselor, Translator, Family
Member, Other:
- What topics were covered during the session?
- WERE THERE ANY PROBLEMS IN SCHEDULING OR COORDINATING
THE TELEHEALTH VISIT?
- No/Yes, Describe
- Establishing communication?, No/Yes
- At what speed were you able to connect?
- 112, 128, 168, 224, 256, 336, 384
- Maintaining communication?, No/Yes
- Operating the camera?, No/Yes
- Sound quality?, No/Yes
- Visual quality?, No/Yes
- Other technical problems?
- ADDITIONAL COMMENTS ON THIS TELEHEALTH SESSION
- PLEASE FAX THE COMPLETED FORMS TO: 514-398-1531
IF YOU HAVE ANY QUESTIONS OR COMMENTS PLEASE CALL GENEVIEVE AT
514-398-3247
BERENS RIVER TELEHEALTH SESSION FORM FAX TO: 514-398-1531
PATIENT CODE, DATE OF VISIT, Time telehealth system disconnected,
PERSON COMPLETING FORM, Time telehealth system connected, TIME
SESSION ENDED
- WHY WAS THE TELEHEALTH SYSTEM USED?
- Patient care: BOX 1, Patient education: BOX 2, Continuing
education: BOX 3, 0ther: WRITE ON BACK OF FORM
- BOX 1: PATIENT CARE
- Who was there at the telehealth session?
- In Berens River
- Patient, Health centre nurse, CHR, Mental health worker,
Physician, Translator, Family Member, Other
- In Winnipeg
- Infectious disease specialist, Psychiatrist, Pediatrician,
Gynecologist/obstet., Nurse, Health educator, Social
worker, counselor, Translator, Family Member, Other:
- What was done during the session?
- Specialist consult
- to discuss or confirm diagnosis, to follow up on previous
visit or on test results
- to discuss case management (medication review/adjustment)
- Prenatal care, Other patient care: describe
- What will happen next?
- No further action is required
- Follow-up is required
- with telehealth, without telehealth
- Patient is to be transferred to
- Other
- Did this session result in avoiding a patient transfer?
(Yes/No/Maybe)
- BOX 2: PATIENT EDUCATION
- individual OR group session - how many attended?
- What was done during the session?
- Diabetes education - what topics?
- Diet/nutrition, Smoking, Insulin, Foot care, Hypertension
- Exercise, Alcohol, Glucose monitoring, Counseling or
support, Other
- Other patient education - what topics?
- BOX 3: CONTINUING EDUCATION
- individual OR group session - how many attended?
- Who was there at the telehealth session?
- In Berens River
- Staff : how many?, Community members:how many?, In
Berens River, Translator, Other
- In Winnipeg
- Specialist, Psychologist, Diabetes educator, Other
educator, Nurse, Social worker, counselor, Translator,
Other
- What topics were covered during the session?
- WERE THERE ANY PROBLEMS IN SCHEDULING OR COORDINATING
THE TELEHEALTH VISIT?
- WERE THERE ANY PROBLEMS WITH ?
- Establishing communication? (No/Yes)
- Maintaining communication? (No/Yes)
- Operating the camera? (No/Yes)
- Sound quality? (No/Yes)
- Visual quality? (No/Yes)
- Other technical problems?
- SUMMARY OF DOCTOR'S COMMENTS
- ADDITIONAL COMMENTS ON THIS TELEHEALTH SESSION
- PLEASE FAX THE COMPLETED FORMS TO: 514-398-1531
IF YOU HAVE ANY QUESTIONS OR COMMENTS PLEASE CALL 514-398-3247
Telehealth Research Project In Fort Chipewyan, Alberta
Monthly Report for the Month of
DESCRIPTION -- STATS
- TOTAL NUMBERS FOR THE MONTH
- Total number of sessions for the month
- Total number of rehabilitation clients seen this month
- Total number of patients that used Televisitation
- Total number of family/friends that used Televisitation
- SPEECH THERAPY
- Total number of Speech sessions
- How many of these were Telehealth
- Total number of Speech clients seen this month
- PHYSIOTHERAPY
- Total number of Physiotherapy sessions
- How many of these were Telehealth
- Total number of Physiotherapy clients seen this month
- OCCUPATIONAL THERAPY
- Total number of Occupational sessions
- How many of these were Telehealth
- Total number of Occupational clients seen this month
- TELEVISITATION
- Total number of Televisitation sessions
- Total number of maintenance/tests/demos of Telehealth
sessions
PROGRESS NOTES:
A= Initial Assessment
B= Ongoing Therapy
C= Adjustment of Therapy
D= Reassessment
E= No therapy needed
F= Discharged
G= Other
SLP Clients - ST-, PT Clients - PT-, OT Clients - OT -
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