Telehealth Documentation: Best Practices for 2025

When telehealth went from exception to standard in mental health practice, documentation guidelines struggled to keep pace. Most state licensing boards have now caught up, but there's still significant variation — and significant confusion — about what telehealth notes actually need to include.

Here's what's changed, what's the same, and what you should be doing.

What's the Same

The clinical content requirements for telehealth notes are identical to in-person notes. A SOAP note for a telehealth session needs the same elements as one for an in-person session:

• Subjective presentation and client report
• Objective observations (adapted for video)
• Clinical assessment including risk
• Treatment plan and next steps

The standard of care doesn't change because the medium changed.

What's Different: The Additions

Telehealth-specific documentation should add several elements that in-person notes don't require:

1. Platform Used

Document the specific platform: "Session conducted via Zoom for Healthcare." This matters for HIPAA compliance verification — if your platform isn't HIPAA-covered, that's a documentation (and legal) problem.

2. Location Documentation

Note where both you and the client were located. This is required in many states because licensure is geographically constrained. "Clinician located in [state]. Client located in [state/city]." For clients in states where you're not licensed, you need to know the rules before you can treat them.

3. Technical Notes

If there were connection issues that affected the session, document them. "Session interrupted by technical difficulties for approximately 8 minutes. Client reported disconnection did not affect therapeutic process."

4. Consent for Telehealth

Your notes should reference that telehealth consent was obtained. This can be a standing note (obtained at intake) or session-specific if you didn't have a prior consent.

5. Emergency Protocol

Document that you have confirmed the client's location and have an emergency contact and local crisis resource for their current location. For a client who has moved since your last session, this is critical.

Objective Observations via Video

The Objective section of telehealth notes is where clinicians most often get stuck. You can't observe gait, body odor, or the full range of physical presentation — but you can observe more than you might think.

Observable via video:

• Facial affect and expressions
• Eye contact (with the camera, noting it's a different dynamic than in-person)
• Grooming and appearance (visible portions)
• Body language (upper body)
• Environment (if visible — can be clinically relevant)
• Speech rate, tone, volume
• Engagement and distraction

A note like "Client appeared via video from home environment, casually dressed and groomed, maintained good eye contact with camera, affect congruent with reported mood" is sufficient objective documentation for a telehealth session.

State-Specific Requirements

Several states have enacted specific telehealth documentation requirements. The most common additions:

• Verbal consent on record: Some states require that you document getting verbal consent to proceed with telehealth at the start of each session
• Location verification: Several states require documenting client location at every session
• Crisis resources: Some states require you to provide local crisis resources to out-of-state clients

Check your specific licensing board's telehealth guidelines — they're usually available on the board's website.

The Crossover Problem: In-Person and Telehealth Clients

Many clinicians now see the same client both in-person and via telehealth depending on the week. Make sure your notes clearly indicate session modality — it matters for billing, continuity, and compliance.

A simple header field ("Session Type: Telehealth / In-Person") prevents confusion in the record and makes audits significantly simpler.

Billing Documentation

Telehealth sessions often use different CPT codes than in-person sessions (typically with a modifier like -95 or -GT). Your note should support the code you're billing. If you're billing a 90-minute telehealth session, your note needs to document time and substantive clinical content that justifies that duration.

The Bottom Line

Telehealth documentation isn't dramatically different from in-person — it's in-person documentation plus a few additional elements: platform, location, consent, and technical notes. The clinical content requirements are unchanged.

The biggest risk isn't what you document — it's what you forget to document because the session felt "less formal" because it happened on a screen. Telehealth notes deserve the same rigor as any other clinical record.