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Telehealth has changed where medical conversations happen, but the basic responsibility to document patient care remains. Clinicians still need accurate records of symptoms, assessments, treatment decisions, medications, follow-up instructions, and other information relevant to the encounter. What is changing is how that information can be captured and organized. According to the ONC (Office of the National Coordinator for Health Information Technology), accurate and complete clinical documentation is foundational to patient safety, care coordination, and appropriate reimbursement — regardless of whether care is delivered in person or through a virtual platform.

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