Telemedicine Documentation Guidelines for Every Visit

Telemedicine Documentation Guidelines for Every Visit

11 Jan 2022
8 min

One of the challenges of providing care via telehealth is that it can be difficult to document in a way that meets all of the requirements of regulatory agencies. In this article, we'll share a few telemedicine documentation guidelines to ensure a successful telehealth visit.

What Is Telemedicine?

Before we discuss telemedicine documentation guidelines, let us first define what is telemedicine.

Telemedicine is the remote delivery of healthcare services, including diagnosis and treatment, using telecommunications technology. It allows healthcare providers to reach patients via the internet.

Telemedicine has many potential applications.

  • It allows doctors to serve patients in remote or underserved areas.
  • It allows doctors to constantly monitor patients with chronic conditions.
  • It allows patients to see different specialists without the need for travel.

Telemedicine can be used to provide a variety of healthcare services, including:

  • Consultations with specialists.
  • Diagnosis and treatment of illnesses.
  • Management of chronic conditions.
  • Health education.
  • Patient monitoring.

Telemedicine can be used by a variety of healthcare providers such as:

  • Physicians.
  • Nurse practitioners.
  • Physician assistants.
  • Psychologists.
  • Social workers.
Key Takeaway: Telemedicine can be used to provide healthcare services to patients in remote or underserved areas.

The Benefits of Telemedicine

The use of telemedicine has grown exponentially in recent years as technology has advanced. There are many benefits of telemedicine, both for patients and for medical providers.

Perhaps the most obvious benefit of telemedicine is that it can help to improve access to care, especially for patients in rural or underserved areas. In many cases, these patients do not have easy access to a medical provider. Telemedicine can help to bridge that gap by providing access to care that would otherwise not be available.

In addition, telemedicine also makes it more convenient for doctors to conduct appointments or consultations after clinic hours or in cases of emergency.

Key Takeaway: Telemedicine can help to improve access to care, save time and money, and improve the quality of care.

Why Discuss Telehealth Documentation?

Telehealth documentation is important because it helps to ensure that patients receive the care they need and that providers are reimbursed for their services. Documentation also helps to improve communication between providers and patients.

Video telemedicine is a great way to provide care for patients who may not be able to come into the office, but it's important to make sure that you are documenting these visits correctly.

Here are some telemedicine documentation guidelines to keep in mind when billing for telemedicine visits.

  • The names of all participants in the visit (e.g., billing provider, nurse, patient, spouse, or guardian).
  • The type of telecommunication system used.
  • How the patient was identified.
  • The chief complaint or reason for the visit that brought the patient to care.
  • A review of systems.
  • Assessment and plan.
  • Procedures that were performed during the visit.
  • Orders that were written during the visit.

Remember, when in doubt, document, document, document!

(How to Conduct Pain Evaluation Through Telemedicine)

Telemedicine Documentation Guidelines

COVID-19 has forever changed how we provide healthcare. And, it seems that telehealth is here to stay.

The pandemic forced providers and patients to adapt to a new way of receiving and delivering care. And, now that we've had a taste of the convenience and accessibility of telehealth, it's likely that many of us will continue to use it even after the pandemic is over.

One of the challenges of providing care via telehealth is that it can be difficult to document in a way that meets all of the requirements of regulatory agencies.

Here are nine tips for clinical documentation in a telehealth setting.

Telehealth Platform: Document in a patient's medical record which method of telemedicine was used. For example, you might write "secure video conference" or "asynchronous diagnostic test follow-up by portal/text/email."

Remote Location: Make sure to note where the patient is physically located. For example, "at home in Tennessee" is necessary for billing purposes and regulatory or professional liability action.

Document where the provider is located such as "in the office," "at the hospital" or "at the clinic."

Informed Consent: Be sure to obtain consent from a patient before initiating a telemedicine appointment. Tell your patients that there may be technical issues and that you may need to convert a telehealth consultation to an in-clinic one if the issue cannot be resolved.

Patient Identity: Verifying a patient’s identity helps reduce the risk of fraud. When a new client comes in, ask them to hold their ID up to the camera and document their confirmation.

Your clients should also ask to see your credentials.

Appropriateness: Check in with a patient’s condition to determine if they are a good candidate for a telemedicine appointment. If the patient is confused or unable to answer basic questions, it may be best to reschedule the consultation.

Document your assessment of the patient’s condition, the environmental factors, the actions you took, and your recommendations for treatment.

Participants: When documenting a visit, be sure to include everyone on the patient and the provider's side. This includes anyone on the patients' end who may have been present at the appointment, including children.

Also, include any assistants that were on the providers' side of things, such as a nurse or social worker.

Assessment: Patients can help out during physical exams by weighing themselves, measuring their vitals, and reporting on their home test results. Make sure to record the results as "Patient Provided" or "Assisted."

Safety: As the number of virtual appointments increases during the COVID-19 crisis, healthcare providers are gaining a look into their patients’ homes that they wouldn’t normally see. This is a great opportunity, but can also be challenging.

Providers can assess for safety issues like falls, allergies, and medications. They can also check for signs of unsafe living conditions, such as potential hoarding, uncleanliness, and neglect. Document these observations, any conversations with patients, and recommendations for the next steps.

Quality Improvement: As part of telemedicine visits, consider incorporating these recommended electronic health record template changes into your current workflow. Evaluate your documentation and processes periodically to ensure compliance.

Keeping these nine best practices in mind can help your healthcare organization create effective, patient-centric, and comprehensive telemedicine documents.

Additionally, it’s important to familiarize yourself with the regulatory requirements and reimbursement guidelines specific to your geographical location(s).

Guidelines for Documentation in a Telemedicine Visit

In a world where technology keeps advancing, it's no surprise that the medical field has also adopted many new technologies – one of which is telemedicine.

One of the benefits of telemedicine is that it can help save lives in emergency situations. For example, if a patient is having a heart attack, a telemedicine doctor can provide instructions on how to perform CPR until emergency medical services arrive.

Another benefit of telemedicine is that it can improve access to care for patients in rural areas. These patients often have to travel long distances to see a doctor, which can be very difficult especially if they are sick or injured. With telemedicine, they can receive the care they need without leaving their homes.

If you are a provider who is thinking about using telemedicine, there are certain guidelines that you need to follow in order to ensure that you are providing quality care.

These telemedicine documentation guidelines are important because they help to protect both the patient and the provider.

One of the most important things to keep in mind when providing care via telemedicine is to make sure that you document everything. This includes documenting the reason for the visit, the conversation that took place between the patient and the provider, and any instructions that were given. It is also important to document any changes in the patient's condition.

Another important guideline is to make sure that you are using HIPAA-compliant software. This software will help to protect the patient's privacy and will ensure that their health information is secure.

Finally, it is important to remember that telemedicine is not a replacement for in-person visits. There are certain situations where a face-to-face visit is still the best option. For example, if a patient is having a life-threatening emergency, it is always best to go to the emergency room.

When used correctly, telemedicine can be a great tool that can help to improve the quality of care that patients receive. By following the guidelines above, you can help to ensure that you are providing the best care possible.

Pro tip: Use Upvio to its full potential by taking advantage of the feature that allows you to capture notes and information during video consultations.

Key Takeaway: Telemedicine can be a great way to improve patient care, but it's important to follow guidelines (including documenting everything) to ensure quality care.


Telehealth has become an essential part of healthcare delivery during the COVID-19 pandemic. And, while it has its challenges, it also offers many advantages both for providers and patients. We hope that these telemedicine documentation guidelines will help you to provide quality care and documentation in a telehealth setting.

If you are interested in adding telemedicine to your practice, Upvio can help you get started.

Maximize the use of Upvio's feature to capture notes and information during video consultations. All shared files are securely stored in the patient portal for easy access by both patients and staff. Additionally, use the file sharing function during virtual appointments to effectively exchange relevant information with patients and staff. This will not only streamline the consultation process but also enhance patient satisfaction.

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