TeleMed Encounter Sheet

TeleMed Progress Note
Name
First NameLast Name
Date
MonthDayYear
Date
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Facility of Service*
Telehealth Consultations*
Emergency DepartmentInpatient
Service Type*
G0425 - Telehealth consultation, emergency department or initial inpatient, typically 30 minutes communicating with the patient via telehealth99231 - Subsequent hospital care, per day, for the evaluation and management of a patient, 15 minutesG0426 - Telehealth consultation, emergency department or initial inpatient, typically 50 minutes communicating with the patient via telehealth99232 - Subsequent hospital care, per day, for the evaluation and management of a patient, 25 minutesG0427 - Telehealth consultation, emergency department or initial inpatient, typically 70 minutes or more communicating with the patient via telehealth99233 - Subsequent hospital care, per day, for the evaluation and management of a patient, 35 minutes
Diagnosis*
F43.23 - Adjustment disorder with mixed anxiety and depressed moodF43.20 - Adjustment disorder, unspecifiedF43.22 - Adjustment disorder with anxietyF43.21 - Adjustment disorder with depressed moodF43.25 - Adjustment disorder w mixed disturb of emotions and conductF41.9 - Anxiety disorder, unspecifiedF41.1 - Anxiety disorder, GeneralizedF90.0 - Attention-deficit hyperactivity disorder, predominantly inattentive typeF90.2 - Attention-deficit hyperactivity disorder, combined typeF06.1 - Catatonic disorder due to known physiological conditionF84.0 - Childhood autismF34.1 - Dysthymic disorderF32.0 - Major depressive disorder, single episode, mildF32.1 - Major depressive disorder, single episode, moderateF32.9 - Major depressive disorder, single episode, unspecifiedF33.0 - Major depressive disorder, recurrent, mildF33.1 - Major depressive disorder, recurrent, moderateF33.2 - Major depressive disorder, recurrent severe without psychotic featuresF42.2 - Mixed obsessional thoughts and actsF40.228 - Other natural environment type phobiaF41.0 - Panic disorder without agoraphobiaF60.9 - Personality disorder, unspecifiedF43.10 - Post-traumatic stress disorder, unspecifiedF43.12 - Post-traumatic stress disorder, chronicZ63.0 - Problems in relationship with spouse or partnerOther
Signature*
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TeleMed Progress Note