Urgent Care Telehealth Protocol for Beginners: High Quality Documentation: No Representation Without Documentation
Do’s: Verify, don’t TRUST
- Always document allergies
- Check HT/WT, if BMI greater than 26, refer to Obesity Medicine, Nutrition and Integrative/Functional Medicine
- Prescribe Augmentin 875 mg BID for 7 days, Zithromax 500 mg QD for 3 or 5 days, Leavaquin 500 mg for 5-7 days, and Nitrofurantoin 100 mg BID for 7 days for Sx UTI. Hydrate with 2,000 ml distilled water/Pedialyte for 10 days or daily
- Tamiflu protocol: up to 4 days of symptoms 75 mg BID for 5 days, by 5 days of symptoms Rx patient with Abx (aforementioned). For COVID symptoms for up to 4 days, Rx with Paxlovid for 5-7 days
- Always inform patient that they must go to ER/urgent care center if Sx persist/worsen/wax-wane in 24-48 hours
- UTI protocol: check for CVA tenderness, and pink/red urine in toilet/gross hematuria
- For ICD 10, always additionally code for SIRS/Sepsis when appropriate
- Sinusitis/Pharyngitis/Otitis Media protocol: Check for anterior/posterior cervical adenopathy/muscle tenderness/pain. Place chin on chest to evaluate for nuchal rigidity/neck suppleness, if positive increased risk for meningitis
- Bronchitis/Pneumonia protocol: make sure to check for productive cough and pleuritic chest pain
- Have a low threshold to send patient to ER/urgent care center
Don’ts: must send to urgent care center/ER
- Rx chest pain, send for cardiac enzymes/PA-lateral CXR
- Rx failure of Abx Rx
- Rx tooth abscess, send to dentist or above, need X-ray
- Rx arrhythmia, evaluated by wearable or if blood pressure cuff says it can’t read the rhythm
- Rx abdominal pain, only if absolutely sure that it is gastroenteritis and inform about visiting ER/urgent care center in 24-48 hours
- Rx possible Fx, send for X-rays
- Rx digit/hand or foot/toe infection that cover several joints with inability to flex or extend. Again, if need X-ray sent to urgent care/ER
- Refills only give 15-30 days supply, insist they see PCP/PMD
- Don’t Rx chronic Dz, send to PMD/PCP and appropriate specialist (neurology, endocrinology, cardiology, pulmonology, allergy-immunology, gyn-urology, endometriosis specialist-reproductive endocrinology, and rheumatology), document clearly in chart