You’re covering a small hospital via telepsychiatry. Police bring in a man found yelling in traffic about government surveillance. The nurse starts the video, but he won’t talk and glares at the screen, saying, “I know what this is.” The team isn’t sure if he’s refusing care or too paranoid to engage. They ask: Can you assess him like this? Should they place a hold? And how do you decide, through a screen, what meds or safety measures to use if he escalates?

Cases like this are now routine for hospital psychiatrists, especially those working remotely. Telepsychiatry has become a standard part of emergency and inpatient care, driven by workforce shortages, after-hours needs, and, not least, the COVID-19 pandemic (Gujral K et al, Telemed J E Health 2025;31(9):1074–1095). Here’s how it works, what challenges to expect, and how to make it go smoothly.

Why hospitals are turning to telepsychiatry
For hospital psychiatrists, telepsychiatry isn’t just a convenience; it’s increasingly the only way to ensure timely consultation. Hospitals of every size are turning to telepsychiatry to fill widening coverage gaps. Many facilities lack in-person psychiatric services, especially after hours or in rural regions (Natafgi N et al, Curr Psychiatry Rep 2021;23(11):72). Smaller hospitals may have only sporadic access to general psychiatrists, who may not be current in emergency or consultation-liaison psychiatry.

Telepsychiatry helps bridge those gaps. Hospitals that have on-site coverage during the day often bring in remote psychiatrists for nights and weekends. Facilities that don’t need full-time staff can access psychiatric care as needed without a permanent team. Correctional settings and state hospitals rely on telepsychiatry to manage persistent staffing shortages.

What telepsychiatry looks like in practice
Most hospital telepsychiatry uses a hybrid model. On-site nurse practitioners or physician assistants handle assessments and patient interaction, while the psychiatrist joins remotely to guide care, join rounds, and document. Thanks to modern electronic health records (EHRs), which have features like embedded video, shared notes, and secure messaging, this setup is more seamless than ever (Vakkalanka PV et al, Telemed J E Health 2023;29(8):1224–1232).

If you provide telepsychiatry, your role varies by setting. On medical floors or in the emergency department (ED), you usually function as a consultant, with the admitting or ED physician entering orders and implementing safety measures. However, when treatment or restraint decisions are based on your recommendations, responsibility is shared, and your documentation should clearly reflect your assessment, your rationale, and any limitations of the telepsychiatric evaluation. On an inpatient psychiatric unit, you serve as the attending psychiatrist and enter orders directly.

One legal note: You must be licensed in the patient’s state and credentialed at the hospital. Practicing across state lines without the proper licensure remains a common and risky pitfall (Shore JH et al, Telemed J E Health 2018;24(11):827–832).

Practical workflow tips
Unlike outpatient telehealth, where patients log in from home, hospital-based telepsychiatry uses hospital-owned tablets or carts. Nurses usually handle setup, like booting up the device, positioning the camera, and standing by to assist or ensure safety. If you’re consulting on an agitated or confused patient, be prepared for mishaps like damaged devices. Hospitals often keep backup tablets for this reason.

Before the telepsychiatry encounter

• Review labs, vitals, and nursing notes ahead of time.
• Ask ED or floor staff to stay nearby during the interview.
• Clarify who’s responsible for orders and safety precautions; don’t assume it’s understood.
• Confirm the patient’s legal status and capacity. For voluntary patients, obtain and document consent for telepsychiatry. For involuntary patients, proceed as clinically indicated, seeking assent when possible and documenting assent or refusal. 
• Check that the patient is in a private setting and that the connection is clear and secure.
• Have a backup plan in case the video fails (eg, switching to a phone call).

During the interview

• Express empathy out loud. In video visits, nonverbal cues often get lost. Make your support explicit. Phrases like “I can see this is overwhelming” can go a long way.
• If a patient seems paranoid or overstimulated, consider starting with audio only, then switching to video once rapport is built.
• If needed, walk on-site staff through basic neurologic or movement checks to help assess for catatonia, akathisia, or other medication-related syndromes.
• When delirium is a concern, ask on-site staff to complete a brief proxy screen such as the Stanford Proxy Test for Delirium (Maldonado JR et al, Psychosomatics 2020;61(2):116–126).

After the evaluation

Summarize the differential and provide clear recommendations. For example: “This patient is exhibiting acute mania with severe disorganization and poor judgment. Initiate a psychiatric hold for danger to self or grave disability. Start olanzapine 10 mg PO now and 5–10 mg PO every 6 hours as needed for severe agitation. If the patient refuses oral medication or becomes unsafe to manage, notify on-site clinician for in-person evaluation and consideration of emergency IM medication. Obtain urine tox screen, CMP, and ECG to check for substances, metabolic disturbances, and QT prolongation.”

• Confirm who’s entering orders and following up on safety precautions.
• Coordinate with social work for collateral and discharge planning.
• Document the encounter clearly, including safety plans, sitter levels, who assisted on-site, and any technical issues during the visit.

Where telepsychiatry can fall short
Telepsychiatry works well most of the time, but it has limits. You’ll likely run into these common scenarios:

• A paranoid patient may refuse to engage, thinking the video camera is part of the conspiracy.
• A severely depressed or catatonic patient may barely speak, making the interview ineffective.

For conditions where the physical exam is critical (eg, serotonin syndrome, neuroleptic malignant syndrome, medication toxicity), you’ll need to rely on the ED team or escalate to in-person care. Close collaboration with on-site staff is key to overcoming these gaps.

Carlat Verdict: Telepsychiatry has become a core part of hospital psychiatric care, not just for emergencies or rural sites, but across EDs, med-surg units, and even psychiatric floors. It’s efficient, flexible, and increasingly easy to implement thanks to EHR-integrated video tools. Still, some cases demand hands-on assessment. Know when to ask for help, make your communication explicit, and don’t assume your note speaks for itself.