Seven Tips for Telehealth Clinical Documentation

Sue Boisvert, BSN, MHSA, Patient Safety Risk Manager II, The Doctors Company

The standards of care for telehealth are identical to those for onsite medical care: Medical and dental professionals must practice with the same level of skill and expertise as qualified practitioners in the same specialty under the same circumstances.

State regulations and associated rules define what constitutes telehealth, third-party payer contracts outline medical necessity expectations and the services that qualify for reimbursement, your organization’s policies and procedures define practice expectations, and case law clarifies the interpretation of all these standards. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and supporting your defense in the event of a professional board complaint or medical professional liability claim.

The following seven tips outline unique considerations for documenting telehealth care:

  1. Modality. Specify clearly in the medical record what modality of telehealth is being used. Examples include “secure interactive audio-video session using Skype,” “medication management visit conducted by telephone,” or “asynchronous diagnostic test follow-up by portal/text/email.”
  1. Geography. Note the patient’s physical location and geography. For example, including “at her home in Tennessee” is important for billing purposes and for determining venue in the event of a regulatory or professional liability action. Also include the provider’s location (“clinic name and city” or “home office and city”) in the documentation.
  1. Informed consent. Advise patients before asking them to consent to treatment by telehealth—about the unique risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and the potential for converting the visit to an in-office visit based on the patient’s needs. In the progress note, include a summary of the discussion and the patient’s decision, as well as a copy of the signed form if used. Find our sample Telehealth Informed Consent form on our Informed Consent Sample Forms page.
  1. Identity. Confirm the identity of new patients by asking them to hold a photo ID close to the camera. Document confirmation of patient identity. Patients also have the right to ask for provider identification.
  1. Appropriateness. Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate based on their cognitive status. If the patient is unable to answer questions or provide an accurate history and no support person is available, the visit may need to be rescheduled. Documentation in this situation might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Evaluate and address distractions in the environment. Carefully document the patient assessment and environmental conditions as well as any actions taken and recommendations made. For more information on addressing patient distractions, see our article “Telehealth’s Newest Safety Risk: Distracted Patients.”
  1. Others present. Document the record with the name and relationship of everyone who is present on the patient’s side of the interaction and the names and roles of everyone present on the provider’s side. The patient’s family members may be present, or the patient may be a minor. For example, document “visit conducted with child sitting on mother’s lap.” Clinical assistants, students, or a scribe may be present on the provider’s side. An interpreter may assist from a third location by video or telephone. Include documentation of all participants.
  1. Assisted assessment. Plan in advance and provide instructions for patient assistance, such as for patients who will obtain and report their own vital signs (including weight, blood pressure, pulse, and temperature). Document the information in the medical record as “patient provided.” If patients also assist in various aspects of physical examination, document the details as “patient assisted.” For more information on patient-assisted assessment, see our article “Strategies for Effective Patient-Assisted Telehealth Assessments.”

Following these seven tips can help you ensure that your telehealth documentation is patient centered, comprehensive, and effective. You can also benefit from familiarizing yourself with the regulatory and payer requirements specific to your practice location(s).

For additional guidance, see our on-demand education, Telemedicine to Telehealth: Trends and Emerging Risks, or contact the Department of Patient Safety and Risk Management at (800) 421-2368 or by email.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J12828 05/21

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Medical Advantage Group, a member of TDC Group, helps organizations quickly launch telehealth services and provides support for implementation and training. And they do it all remotely.