Telehealth Documentation Requirements
When documenting a telehealth visit, you must include the name of any person helping with accessories on the patient side, along with several other telehealth-specific elements that are not required for standard in-person visits. 1, 2
Essential Telehealth-Specific Documentation Elements
The American Telemedicine Association mandates that telehealth documentation must include the following components that go beyond standard clinical documentation: 1
- Patient consent to telemedicine – explicit documentation that the patient agreed to the telehealth modality 1, 2
- Method of telemedicine – specify whether audio-video or audio-only, and the HIPAA-compliant platform used (e.g., "Zoom for Healthcare," "Doxy.me") 2
- Patient location – document where the patient is physically located during the encounter 1, 2
- Provider location – document where you are physically located 1, 2
- All clinical participants' roles and actions – this includes the name and role of anyone assisting on the patient side (e.g., "Medical Assistant Jane Smith assisted with positioning patient and managing camera") 1
- Other individuals present at the visit – document anyone else in the room with the patient or provider 1
Standard Clinical Documentation Still Required
Beyond these telehealth-specific elements, all standard clinical documentation requirements apply equally to telehealth encounters: 3
- Patient's past medical history – this remains a fundamental component of any clinical encounter, whether in-person or virtual 3
- Chief complaint, history of present illness, review of systems 3
- Physical examination findings (with acknowledgment of any limitations due to the virtual format) 3, 2
- Assessment and plan, including diagnosis with ICD-10 codes 2
- Medical decision-making complexity 1, 2
What Is NOT Required in Routine Documentation
The following elements are not standard requirements for telehealth visit documentation:
- Brand and model number of telehealth equipment – while you should document the platform used (e.g., institutional EHR video system), specific equipment model numbers are not required 2
- Provider's license and DEA number – these are credentialing elements, not documentation requirements for individual visit notes. However, you must ensure you are licensed in the state where the patient is physically located 3, 2
Critical Pitfalls to Avoid
Licensure verification is a compliance issue, not a documentation issue. You must be licensed in the state where the patient is located during the telehealth visit, but this is verified through credentialing processes, not by documenting your license number in each note. 3, 2
Failing to document the patient presenter or assistant is a common error that can create compliance and liability issues, as the identity and role of all participants must be clear for medicolegal purposes. 3, 1
Documentation must justify why telehealth was appropriate for the specific clinical scenario and note any limitations of the virtual examination that might affect clinical decision-making. 3, 2