Core Documentation Requirements
Essential elements that must be documented for telehealth visits
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
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
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
HIPAA and state privacy laws
Billing & Coding
- Use appropriate telehealth modifiers (95, GT, etc.)
- Document medical necessity for virtual care
- Record visit duration and complexity
- Note patient location (for billing purposes)
- Include provider location and credentials
CMS and insurance payer requirements
Virtual Physical Examination Guidelines
Best practices for conducting physical examinations via telehealth
General Appearance
Virtual Examination Techniques
- 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
Virtual Examination Techniques
- 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
Virtual Examination Techniques
- 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
Virtual Examination Techniques
- 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
Telehealth Compliance Checklist
Comprehensive checklist to ensure regulatory compliance
Pre-Visit Preparation
- 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 HIPAA-compliant environment for provider
During the Visit
- Document start and end times of virtual encounter
- Record technology platform and any technical issues
- Perform appropriate virtual examination
- Obtain and document informed consent if not previously done
- Ensure patient privacy and confidentiality
Post-Visit Documentation
- Complete clinical notes within 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
Key Regulatory Considerations
Important state and federal regulations affecting telehealth practice
Licensure Requirements
Provider must be licensed in state where 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
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
Enhanced privacy requirements for virtual care
Key Implications:
- HIPAA-compliant platforms required
- Secure data transmission and storage
- Patient consent for technology use
- Provider environment privacy considerations
Telehealth SOAP Note Template
Structured template for documenting virtual care encounters
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
Telehealth Documentation Best Practices
Expert recommendations for high-quality virtual care documentation
Do's
- 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'ts
- ✗Use non-HIPAA compliant video platforms
- ✗Assume virtual visits require less documentation
- ✗Forget to document patient consent for telehealth
- ✗Ignore state licensing requirements for patient location
- ✗Provide care beyond the scope of virtual examination