Instructions for remote medical examination between health officials and patients

Instructions for remote medical examination between health officials and patients are as follows:

Cases where the patient meets the health officials for the first examination

A patient is determined to be examined for the first time when:

- The patient has never examined or consulted with this health official before;

- Or the patient has been examined by this health official before, but more than 6 months since the current examination, or has been examined within the past 6 months but with another health problem.

Step 1: Start the examination and consultation

- Depending on the situation, patients can proactively contact health officials, make an appointment using the software, make audio or video calls with health officials, or send emails or text messages with health questions to start the remote medical consultation; Health officials respond to accept and perform the remote consultation.

Step 2: Identify and confirm the patient's consent

- Health officials greet and reintroduce themselves by name, age, and work position;

- Health officials ask again for the patient's name, age, address, phone number, or other identifying information, to determine the patient's identity;

- Health officials enter patient identification information into the health officials' notes on the medical registration form or corresponding information fields on the software;

- Health officials agree with the patient on the purpose and content of the examination and consultation and reaffirm the patient's agreement and readiness to begin the remote examination and consultation.

Step 3: Quickly assess the patient's condition

- Health officials quickly assess whether the patient's condition requires urgent or emergency care;

- If the patient needs urgent intervention, health officials briefly explain to the patient, advise on immediate first aid, and provide referral instructions when appropriate;

- If the patient does not have a condition that requires urgent intervention, health officials will clearly explain the related issues to the patient and continue to carry out routine remote examination and consultation steps.

Step 4: Collect and exchange information to evaluate the patient

- Health officials shall ask and request that the patient provide relevant information.

Step 5: Provide a treatment plan for the patient

- If the condition can be appropriately managed through remote health care, then health officials can provide a professional assessment of the patient;

- Provide general health promotion educational information to appropriate patients;

- Provide advice on both pharmacological and non-pharmacological treatments and make appointments for the next visit, if necessary;

- Provide guidance on specific treatment methods by prescribing drugs suitable for a definite or provisional diagnosis and in accordance with the lists recommended for use according to each method of remote medical examination and consultation. . In addition, health officials also provide advice and guidance on supportive and additional treatment measures, if any;

- Health officials enter information about symptoms, diagnoses, treatment instructions, and instructions, instruct patients to view and follow instructions on the patient's application account.

Cases where the patient meets with health officials for a follow-up examination

Step 1: Start the examination and consultation

- In a typical situation, according to the appointment, the patient contacts the health officials who are managing their treatment to receive a remote examination and consultation services to continue the ongoing treatment. Sometimes patients may contact health officials without an appointment to seek advice about a new health problem that has arisen during treatment.

Step 2: Obtain patient's identification and consent

- Health officials greet when seeing the patient again;

- Health officials should check the patient's personal information (image, phone number, registered email, etc.) to ensure that they are contacting the correct patient who has registered and scheduled an appointment;

- Health officials enter patient identification information into the health officials' notes on the medical examination registration form or corresponding information fields on the software;

- If there is any doubt, health officials can ask the patient to restart the conversation from the registered phone number or email or confirm the patient's identity by asking for the patient's name, age, address, email, or phone number;

- Health officials agree with the patient on the purpose and content of the examination and consultation and reaffirm the patient's agreement and readiness to begin the remote examination and consultation.

Step 3: Quickly assess the emergency situation

- If the health officials determine that the patient's problems are an emergency that requires emergency treatment, they will briefly explain them to the patient, give advice on first aid for immediate emergency care, and provide referral instructions if necessary;

- If there is no emergency problem, proceed with routine follow-up consultation steps.

Step 4: Carry out regular follow-up consultations

- Health officials access and review the patient's previous records (history/medical history/clinical and laboratory results) to obtain additional information for continuing care;

- Health officials decided to collect additional necessary information from the patient for this follow-up visit. From the information collected, health officials will make their professional decisions regarding the type of consultation and the patient's condition;

- If more time is needed to seek additional information, health officials may decide to pause the remote examination and consultation session and resume at the appropriate time when additional information has been received.

Step 5: Provide a treatment plan for the patient

- After having all the necessary information about the patient, if you think that the patient's health condition can be appropriately managed by a remote examination, health officials will provide appropriate treatment management plans for patients remotely;

- Depending on the situation, health officials may decide to offer one or more treatment options to the patient: (1) provide general health education information; (2) consultation related to specific clinical conditions; and/or (3) prescribe medication for patients;

- In case a prescription is needed, if the patient is re-examined for the same health problem that was previously managed and treated and no new situations arise, health officials may re-prescribe the previous medication so that the patient can continue using it according to the treatment schedule. Sometimes health officials may also consider prescribing a new medication, as a “complementary” medication to optimize the management of the patient's condition. If the patient has additional situations related to the disease and the prescription being treated, health officials can replace the drug with a new one on the list of treatment drugs appropriate to the type of consultation for the patient;

- If during the follow-up consultation, health officials discover new symptoms related to another disease in the patient, they will take the same steps as in the case of the patient receiving a remote medical examination for the first time.

More details can be found in Official Dispatch 7946/BYT-KCB, dated December 12, 2023.

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