Telehealth Documentation Requirements
What to document for video and phone visits — consent, patient location, the virtual exam, billing codes and the regulations that apply — so a virtual note holds up as well as an in-person one.
The essentials
Core documentation requirements
The elements every telehealth visit note needs, on top of your usual clinical content.
Patient consent & authorization
- Obtain informed consent for telehealth services
- Document patient's understanding of technology limitations
- Record consent for recording (if applicable)
- Verify patient identity and location
- Document emergency contact information
Why: Required by state regulations and professional boards
Clinical documentation
- Document chief complaint and history of present illness
- Record virtual physical examination findings
- Note technology platform used for visit
- Document any technical difficulties encountered
- Include assessment and treatment plan
Why: Same standards as in-person visits apply
Technology & security
- Use HIPAA-compliant video platforms
- Document platform security features used
- Record any technical issues or interruptions
- Verify secure transmission of patient data
- Maintain audit logs of virtual visits
Why: HIPAA and state privacy laws
Billing & coding
- Use appropriate telehealth modifiers (95, GT, etc.) as each payer requires
- Document medical necessity for virtual care
- Record visit duration and complexity
- Note patient location (for billing purposes)
- Include provider location and credentials
Why: CMS and insurance payer requirements
The virtual exam
Virtual physical examination guidelines
What you can assess on camera, by body system — and the limitations you should write into the note.
General appearance
What you can do
- Observe patient's overall appearance and demeanor
- Note grooming, posture, and general health status
- Assess for signs of distress or discomfort
- Document any visible abnormalities
Limitations to document
- Limited ability to assess subtle physical findings
- Dependent on camera quality and lighting
- May miss non-verbal cues
Cardiovascular
What you can do
- Observe for visible signs of cardiovascular distress
- Ask patient to check pulse if capable
- Assess for edema in visible extremities
- Note any visible jugular vein distention
Limitations to document
- Cannot perform auscultation remotely
- Unable to palpate pulses or assess blood pressure
- Limited assessment of heart sounds
Respiratory
What you can do
- Observe respiratory rate and effort
- Note use of accessory muscles
- Assess for visible cyanosis
- Listen for audible wheezing or stridor
Limitations to document
- Cannot perform chest auscultation
- Unable to assess chest expansion
- Limited ability to detect subtle respiratory sounds
Neurological
What you can do
- Assess speech clarity and cognitive function
- Observe facial symmetry and expressions
- Test gross motor function if possible
- Evaluate coordination through simple tasks
Limitations to document
- Cannot perform detailed neurological testing
- Limited assessment of reflexes
- Unable to test fine motor skills adequately
Write the limitations down
Visit by visit
Telehealth compliance checklist
Run through these before, during and after every virtual visit.
Before the visit
- Verify patient identity using two identifiers
- Confirm patient location and emergency contact
- Test technology platform and backup options
- Review patient's medical history and current medications
- Ensure a HIPAA-compliant environment for the provider
During the visit
- Document start and end times of the virtual encounter
- Record technology platform and any technical issues
- Perform an appropriate virtual examination
- Obtain and document informed consent if not previously done
- Ensure patient privacy and confidentiality
After the visit
- Complete clinical notes within the required timeframe
- Include telehealth-specific elements in documentation
- Send appropriate follow-up instructions
- Schedule necessary in-person visits if indicated
- Ensure proper billing codes and modifiers are used
Quality assurance
- Review documentation for completeness
- Verify compliance with state and federal regulations
- Assess patient satisfaction with virtual care
- Monitor outcomes and follow-up compliance
- Maintain continuing education on telehealth best practices
Billing & coding
Place of service codes and modifiers
Errors in place of service codes and modifiers are among the most common causes of telehealth claim denials.
POS 02Telehealth provided other than in the patient's home
The patient is at a healthcare facility, clinic or other non-home location. Paid at the facility rate (lower).
POS 10Telehealth provided in the patient's home
The patient is at home. Paid at the non-facility rate, typically higher than POS 02 — a differential formalized beginning in CY 2024.
Telehealth modifiers
- 95
- Synchronous audio-video visit. The primary modifier for standard video visits with commercial payers.
- 93
- Audio-only (telephone) visit. Required for Medicare audio-only; document that video was available but the patient could not or chose not to use it.
- GT
- Legacy audio-video modifier, largely superseded by POS codes. Some payers may still require it.
- GQ
- Asynchronous (store-and-forward). For Medicare, used primarily in Alaska and Hawaii.
- FQ
- Audio-only service. Used in specific circumstances by RHCs and FQHCs.
E/M codes for Medicare telehealth
Payer rules change often
Regulations
Key regulatory considerations
Important state and federal rules that affect telehealth practice.
Licensure follows the patient
Licensure requirements
The provider must be licensed in the state where the patient is located.
Key implications
- May require multiple state licenses
- Interstate compacts may apply
- Temporary waivers during emergencies
- Verification of patient location required
Prescribing regulations
Controlled substance prescribing may be restricted.
Key implications
- DEA registration requirements
- State-specific controlled substance rules
- Prior relationship requirements
- Prescription monitoring program compliance
Standard of care
The same standard of care applies to virtual visits.
Key implications
- Appropriate patient selection for telehealth
- Recognition of technology limitations
- Referral for in-person care when needed
- Proper documentation of clinical decisions
Privacy and security
Virtual care carries enhanced privacy requirements.
Key implications
- HIPAA-compliant platforms required
- Secure data transmission and storage
- Patient consent for technology use
- Provider environment privacy considerations
Template
Telehealth SOAP note template
A structure for documenting virtual encounters, with the telehealth-specific elements built in.
Telehealth visit
SOAP format
Subjective
- Chief complaint and history of present illness
- Review of systems (adapted for virtual format)
- Current medications and allergies
- Social history relevant to current complaint
- Technology platform used and patient comfort level
Objective
- Virtual physical examination findings
- Technology platform and quality of connection
- Patient's ability to participate in virtual exam
- Any technical difficulties encountered
- Vital signs if obtained by patient or caregiver
Assessment
- Clinical impression based on virtual encounter
- Limitations of virtual examination noted
- Differential diagnosis considerations
- Risk stratification and urgency assessment
- Appropriateness of virtual care for this condition
Plan
- Treatment recommendations and prescriptions
- Follow-up plans (virtual or in-person)
- Patient education provided during visit
- When to seek emergency care instructions
- Next scheduled telehealth or office visit
Best practices
Telehealth documentation do's and don'ts
Do
- Document the technology platform used and connection quality
- Note any limitations of the virtual examination
- Include patient location and emergency contact information
- Use appropriate telehealth billing codes and modifiers
- Maintain the same documentation standards as in-person visits
Don't
- Use non-HIPAA-compliant video platforms
- Assume virtual visits require less documentation
- Forget to document patient consent for telehealth
- Ignore state licensing requirements for the patient's location
- Provide care beyond the scope of a virtual examination
Compliant telehealth notes, without the typing.
ReasonNotes writes a complete note from your video or phone visit — ready to review in about a minute. HIPAA compliant with a BAA on every plan, and recordings are deleted once the note is written.
Keep reading