[Andres Peralta Mazzitelli]

In this Telehealth visit I (Andres Peralta) was the Family Nurse Practitioner and Anna Przybylska was the patient with a new diagnosis of Diabetes. She is being treated with metformin, exercise, and diet changes. Her latest A1C was 6.8 and she states she has not been taking her medication every day, she has not been checking her blood sugar as ordered, she still is eating poorly, and she has been exercising a little with her dog daily. Since her last A1C was about 6 months ago, she will need another one in the next week or two. She understood the importance of taking her medication, exercising, and eating healthier. She was educated on this. She is denying feet/leg pain, however, if she starts having symptoms of neuropathy she should let us know, especially if her diabetes is uncontrolled. Other disciplines that could potentially be involved if her current condition becomes unmanageable could be endocrinologist, podiatrist, and dietician. She was also educated on the diabetic sensor and pod, and the advantages of using it. She was agreeable with this. She also agreed to use Medisafe. Other apps that could be helpful could be Fooducate (for nutrition), MyFitnessPal (for exercising tips), and BlueStar (support and education). All past lab results, medication, future interviews, and assessment were discussed with patient and she agreed with plan of care. She expressed happiness regarding the Telehealth visit and she would like to continue follow-up visits using this platform. All information, summary visit, and links were sent to patient via secure email.

Orientation: 5
Verbal Clarity: 5
Active Listening: 5
Patient-Focused: 5
Tone of Voice: 5
Eye Contact:5
Other Body Language: 5
Empathy: 5
Rapport: 5
Respect: 5
Therapeutic Alliance: 5
Environment: 5
Overall: 5

1. Identifies reason for the visit: 1
2. Confirms that patient agrees with the reason for the visit and accepts: 1
that it is delivered by telehealth: 1
3. Obtains history of symptoms or situation: 1
4. Obtains approaches/treatments patient has taken to address the issue: 1
5. Conducts an appropriate physical using equipment at home, and/or other individuals to assist or provides telehealth education using appropriate learning style: 1
6. Discusses findings/Overview of education:1
7. Develop plan (follow-up, referral, medication, etc.): 1
8. Determines patient’s understanding of plan/education: 1
9. Determines how patient will get information on the visit (email, portal, secure text, etc.): 1
Total: 9/9

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