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In clinical documentation, what may seem like a simple digital version of a paper record is, in reality, a complex ecosystem that underpins informed clinical decisions, seamless data exchange, financial performance, and value-based patient care.
Recently, the rapid advancement of teledermatology, projected to grow at over 14% annually from its 2022 market size of $3.01 billion in the U.S., has introduced new challenges to this ecosystem.
During in-person visits, dermatologists can examine the skin directly, palpate lesions, and use diagnostic tools like dermatoscopes to create detailed notes, while teledermatology depends heavily on patient-provided information. This, in turn, increases the risk of subjectivity due to differences in how patients describe symptoms, the quality and timing of submitted images, and inconsistencies in communication.
To address these challenges and elevate the quality of teledermatology documentation, this blog outlines practical strategies such as standardizing image capture protocols, using structured templates, evaluating image quality, and verifying patient history thoroughly.
Let’s dive in.
In virtual consultation, when you are not physically in the room with the patient, the chances to skip relevant queries multiplies. There is no paper chart in front of you, and you depend heavily on photos or videos, which aren’t always clear. That’s why structured notes and consistent templates make such a huge difference here. One of the most commonly used methods for teledermatology documentation is SOAP note templates, which does wonders when equipped with integrated checklists.
This checklist can live directly inside your EHR software, ideally embedded into the SOAP note screen as a collapsible functionality next to each relevant section (e.g., under ‘Subjective,’ have prompts like ‘Itching?’ ‘Bleeding?’ ‘Recent medication change?’,etc.).
History-taking is another area where structure helps. In teledermatology, you want to make sure that things like trigger exposures, stress, new skincare products, or allergen contact, don’t get lost in the shuffle. So, having a detailed history form in your EHR, either as a dedicated tab in the encounter note or as a smart form popup, lets you standardize how this data is captured. Ideally, this form would include dropdowns and short text fields for known triggers, previous treatments (Rx and OTC), and a progression timeline.
Further, when documenting lesions, you can’t afford ambiguity. Especially when you might not have a clear image. A good solution here is to use lesion fields. Think of an interface with labeled input boxes for size, color, border, and distribution, placed either under the ‘Objective’ section or accessible via a ‘Lesion Tracker’ sidebar. This kind of setup ensures you record ‘5 mm, erythematous, scaly plaque on the extensor surface of the right forearm,’ instead of something vague like ‘rash on arms.’ Some dermatology-specific EHRs support this with body diagrams where you can click to mark lesion location, which adds visual clarity to the record.
Finally, one of the easiest wins in teledermatology is automatically generating plain-language patient summaries from your notes. These should be emailed or shown in the patient portal right after the visit. You can include care instructions, medication reminders, and next steps, generally pulled from the ‘Plan’ section of your clinical note.
To further cut documentation time, incorporating smart fields within templates is next to none. These include dropdowns for common findings (e.g., lesion type, location, severity), autocomplete phrases based on frequently used entries, and auto-tagging features that label notes with diagnosis codes or anatomical locations.
These features must be embedded within your EHR’s dermatology templates. If your current EHR lacks these tools, consider working with your vendor or IT team to develop them as part of a clinical documentation improvement initiative.
Besides, prioritizing role-based access further supports a cleaner workflow. For example, medical assistants (MAs) might see only intake and image-capture sections, while nurse practitioners (NPs) handle SOAP notes and physicians review or finalize documentation. This avoids clutter and confusion, making each user’s interface task-focused and secure. Your EHR’s admin or vendor support team can configure these roles for you.
Finally, FHIR and API integrations are vital. Teledermatology doesn’t happen in a vacuum. Labs, pharmacies, and telehealth platforms must be connected. Your EHR should support interoperability standards like FHIR to sync medication lists, lab results (e.g., patch tests), and virtual visit notes.
Many advanced dermatology-focused EHRs also support AI integrations that analyze abscess videos and triage them by urgency or suspected condition. These tools are not built-in by default but can be integrated via API, and your IT or vendor partner should assist in evaluating and deploying these safely and compliantly.
Since you can’t physically examine patients in virtual consultations, photographs become central to making accurate assessments, monitoring disease progression, and planning treatment. To leverage this at its best, focus on capturing high-resolution impressions with consistent lighting, angle, and distance is critical. Many teledermatology platforms now come with built-in camera calibration or can be integrated with mobile apps that guide the patient or clinical staff to take photos at standardized angles. These mobile or desktop apparatus are often linked to the EHR through secure APIs, so the images are directly uploaded to the patient’s chart without needing extra steps.
Sometimes, an image may not clearly show texture, scale, or borders. In such cases, basic editing like cropping, zooming, or adjusting brightness becomes clinically necessary. Choose devices that allow these enhancements but keep the original depiction intact and audit-trailed.
Many dermatology-focused platforms have this, or you can integrate a secure image editing layer into your EHR that supports traceable modifications. Using side-by-side graphics comparison for before-and-after views is another must-have. This feature helps you visually track treatment efficacy over time. Preferably, this remains in your EHR’s imaging section, with the ability to filter by date or treatment phase.
Lastly, all illustrations should be tied to a timeline and documentation trail. Make sure every upload is timestamped, with logs of who viewed or edited it. This history can be essential for legal audits or care continuity. Your EHR must support audit trails for all media files and offer metadata tags (e.g., ‘uploaded by,’ ‘used in consult on,’ etc.). If your current system lacks these, it’s time to evaluate imaging modules or EHR extensions that provide structured media handling for dermatology.
To ensure your documentation is strong enough to justify reimbursement, defend clinical decisions, and maintain high standards of care, every piece of patient data must be stored in a HIPAA-compliant environment.
This means the teledermatology platform you use must either come with built-in secure storage or be tightly fused with your EHR system that uses encrypted, HIPAA-certified servers. If you’re using an app or tool to capture patient data, ensure it uploads directly to your EHR or patient chart without being saved on a local device. Avoid using unsecured channels like texting or generic email.
Next is documenting patient consent. This step is often rushed or skipped, but it’s essential from both a legal and billing perspective. A good system will also automatically record access logs, who viewed what, when, which protects both the patient and provider if any questions arise later. Some telehealth platforms now include automated consent pop-ups or e-signature modules that embed consent forms directly in the patient record.
Practical tip: From a billing perspective, ensure your clinical documentation supports CPT codes like 99212 to 99215 (E/M codes for established patient visits) and time-based codes like 99457 for remote evaluation and management. That way, you’re less likely to be questioned later about whether the visit met the required level of service.
Many advanced EHR systems like OmniMD are designed with built-in billing templates or smart text that help auto-fill justifications based on the visit’s content.
Language access is another key aspect that plays a critical role in building trust and engagement in a setting where in-person interactions are limited. Patients often feel lost in medical jargon, especially in remote care settings, providing multilingual summaries of the diagnosis, treatment plan, and medication instructions can dramatically improve comprehension and compliance.
These should be auto-generated and pushed through the patient portal or emailed through secure channels. Some EHRs like OmniMD, Epic, or eClinicalWorks provide automated discharge instructions with language preferences. But if your system doesn’t, you can layer on third-party translation services like Microsoft Azure Translator through API middleware.
Lastly, gathering patient feedback after each teledermatology consult is a powerful but underused practice. A simple, mobile-optimized feedback form, sent via SMS or in-app notification, can ask about their satisfaction with the consult, the ease of uploading images, and whether they understood the follow-up instructions. Some clinics integrate this feedback loop within their EHR’s patient engagement tools, while others use platforms like Qualtrics or Google Forms, connected via secure email or API.
Nothing can lend peace of mind like a clinical ecosystem that thinks just like you. At OmniMD, we deliver healthcare IT and software solutions designed with deep medical insights and engineering precision and trained to work the way you do. Enhancing diagnosis accuracy and medication efficacy, our AI-powered teledermatology capability suite encompasses:
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