Telehealth Clinical Documentation Strategies

Whether patient care is delivered in person or through telehealth, the required levels of skill and expertise and the standard of care are the same. Clinical documentation plays a significant role in demonstrating regulatory compliance, establishing medical necessity for billing, and defending the practitioner in the event of a licensing board complaint or professional liability claim.

Due to the unique differences between an in-person patient visit conducted on site and telehealth, documentation is key in proving that the care provided was medically necessary and consistent with the standard of care. The practice of telehealth creates additional and specific documentation requirements. Consider the following strategies for documenting telehealth care:

• Modality: Specify clearly in the patient’s record the telehealth modality used. Examples include “secure interactive audio-video session using [name of] telehealth platform,” “telephone medication management consultation,” or “asynchronous diagnostic test follow-up by portal/text/email.”
• Geography: Note the patient’s physical location and geography. For example, including “at her home in Tennessee” is necessary for billing purposes and determining venue in the event of regulatory or professional liability action. Also document the provider’s location, such as “in the clinic,” “from the hospital,” or “from the home office.”
• Informed consent: Obtain informed consent for telehealth visits. Advise patients about the risks of a telehealth visit, including the potential for technical difficulties, information security concerns, and that it may be necessary to convert the visit to an in-office visit depending on patient needs and clinical findings. In the progress note, summarize the discussion, the questions asked and answered, and the patient’s decision. Include a copy of the signed consent form. Find our sample “Telehealth Informed Consent” form on our Informed Consent Sample Forms page.
• Identity: Confirm patient identity to reduce the risk of billing fraud and medical identity theft. Ask new patients to hold a legible photo ID close to the camera. Document confirmation of patient identity. Patients also have the right to ask the practitioner for identification.
• Appropriateness: Determine quickly if the patient and environmental conditions are appropriate for a telehealth visit. Some patients may not be appropriate candidates for telehealth visits based on their cognitive status. If the patient cannot answer questions or provide an accurate history, and no support person is available, the visit may need to be rescheduled or converted to an onsite office visit. Documentation in this situation might include “the visit was rescheduled at the patient’s request because her husband could not be available.” Utilizing the patient’s actual words carries greater credibility in the event of a subsequent dispute or misunderstanding. Evaluate and address distractions in the environment. Document patient assessment, environmental conditions, actions taken, and recommendations made, including specialty referrals or alternative treatment modalities or clinical therapies. For more information on addressing patient distractions, see our article “Manage Patient Distraction During Telehealth Visits.”
• Others present: Include documentation of all participants. Others may be present at the patient’s location and may assist with or affect the quality of the visit. Document in the progress note the name and relationship of all individuals present on the patient’s side of the interaction. For example, document “visit conducted with child sitting on mother’s lap.” On the practitioner’s side, document the names of assistants who are present and their purpose. For example, a medical assistant may serve as a chaperone during remote sensitive visual examinations. In addition, document the use and name of interpreters who assist from a third remote location by video or telephone.
• Assisted assessment: Plan for and provide instructions to patients if they will be performing tasks during the examination. With preparation, patients may be able to measure and report their weight, vital signs, and home point-of-care testing results. Document results and specify the source of the information, such as “patient provided.” When patients 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.”
• Safety concerns: Scan the patient’s environment for possible safety concerns. As the volume of telehealth visits increased during the pandemic, clinicians were afforded a window into patients’ homes and lives that would not otherwise have been possible. This opportunity was both a blessing and a challenge. Visualizing the patient’s surroundings facilitates patient safety activities such as fall reduction, environmental allergy assessment, and brown bag medication checks. In some cases, however, practitioners may see conditions that require intervention that are not directly related to the visit. Examples include evidence of hoarding, unsanitary conditions, abuse, and potential human trafficking. Objectively document observations, discussions with the patient, recommendations, and follow-up plans.
• Quality improvement: Consider revising electronic health record templates to include some of these documentation recommendations as checkboxes, dropdowns, or text macros. Periodically evaluate telehealth visit documentation to ensure compliance with the recommendations.

For additional guidance, contact Patient Safety and Risk Management at (800) 421-2368 or by email.