KO Telemedicine Activity Log

KO Telemedicine Activity Log

Type of Connection:

q  KNet

q  KOTM/NORTH Network

q  Webstreaming

Type of Session:
q  Clinical
q  Family Visit
q  Education
q  CTC Training / q  Demo
q  Admin Meeting
q  Test Call
q  Cancellation
q  Other ______/ q  Scheduled
q  Spontaneous

Date: ______

Time Session Began: ______

Time Session Ended: ______

FOR CLINICAL SESSIONS AND FAMILY VISITS:
Patient Site
Site Location:______
Patient Name:______DOB:______
Band Number:______Health Card Number:______
Patient’s Community of Residence:______
Reason for Consult:______
Referring Physician:______
Name of Telemedicine Coordinator at Patient Site:______
Consult Site
Name of Consultant:______
Specialty (i.e. Diabetes Clinician, Cardiologist, etc.) ______
Location of Consultant Site: ______
FOR EDUCATION SESSIONS, DEMOS, MEETINGS, TRAINING
Topic: ______
Presenter’s Name and Site:______
Participant Site:______
List Attendees at Participant Site below:
______
______
______

Any Problems Experienced? ______

q  Helpdesk notified of any technical problems

q  Cancellation Reported to CSO

Reason(s) for Cancellation: ______

Rebook Appointment? □ Yes □ No

Immediately after the session FAX log to KO Telemedicine Office 807-735-1089

Last revised: May 15, 2007