Telehealth Etiquette Checklist
Evaluation of Angela Poole – Developmental Evaluation
1. Orientation = 5
2. Verbal Clarity = 5
3. Active listening = 5
4. Patient-Focused = 5
5. Tone of Voice = 5
6. Eye Contact = 5
7. Other Body Language = 5
8. Empathy = 5
9. Rapport = 5
10. Respect = 5
11. Therapeutic Alliance = 5
12. Environment = 5
Overall Rating = 5
Angie you did a great job. You were very professional, respectful, and very informative. As a patient I felt that my baby and I were in great hands. Great job!!
Telehealth Exam/Education Rubric- Evaluation of Angela Poole
1. Identifies reason for the visit 1/1
2. Confirms that patient agrees with the reason for the visit and accepts
that it is delivered by telehealth 1/1
3. Obtains history of symptoms or situation 1/1
4. Obtains approaches/treatments patient has taken to address the issue 1/1
5. Conducts an appropriate physical using equipment at home, and/or
other individuals to assist or provides telehealth education using
appropriate learning style 1/1
6. Discusses findings/Overview of education 1/1
7. Develop plan (follow-up, referral, medication, etc.) 1/1
8. Determines patient’s understanding of plan/education 1/1
9. Determines how patient will get information on the visit (email,
portal, secure text, etc.) 1/1
Total: 9/9
