Do I need to document the client's location for every telehealth session?

Yes. You must document the client's physical location (city and state at minimum) at the time of the session. This is not optional — it determines which state's laws govern the session, whether you are licensed to provide services in that jurisdiction, and it is required for insurance billing. Ask the client to confirm their location at the start of every session, even if they are a long-standing client, because they may travel.

What telehealth platform information do I need to document?

Document the name of the platform used (e.g., Doxy.me, Zoom for Healthcare, SimplePractice Telehealth) and confirm that it is HIPAA-compliant. You do not need to document the BAA number in every note, but your practice should maintain a Business Associate Agreement with the platform vendor. If you used a phone call instead of video, document that and explain why (e.g., client's internet was down).

How do I document a telehealth session where the video kept freezing?

Document the technical issues factually: what happened, how long the disruption lasted, whether it affected the clinical content, and how you resolved it. For example: 'Video connection was intermittent from approximately 2:15-2:25 PM. Session was paused, and connection was re-established. Client confirmed no distress related to disruption. Remaining session content was not affected.' If the disruption was significant enough to compromise clinical care, document your decision to continue, reschedule, or switch to phone.

Do I need a separate informed consent for telehealth?

Yes. Most state licensing boards and many insurance companies require a specific telehealth informed consent separate from your general treatment consent. This consent should cover the technology used, privacy risks unique to telehealth, emergency procedures when the client is remote, limitations of telehealth, and the client's right to refuse telehealth in favor of in-person services. Document that this consent was obtained — many clinicians note the date of consent in their first telehealth note and then reference it subsequently.

Can I bill the same CPT codes for telehealth as I do for in-person sessions?

Generally, yes. Most payers accept standard psychotherapy CPT codes (90834, 90837, etc.) for telehealth sessions when delivered via live, synchronous audio-video. You will typically need to add a Place of Service code (POS 10 for telehealth in the client's home, POS 02 for other telehealth locations) and modifier 95 or GT depending on the payer. Always verify the requirements of the specific insurance plan, as policies vary.

Telehealth Session Notes: Documentation Requirements & Template

Progress Notes|9 min read|Updated 2026-03-19|Clinically reviewed

What Are Telehealth Session Notes?

Telehealth session notes are progress notes for therapy sessions conducted via video, phone, or other HIPAA-compliant telecommunications technology. They follow the same general structure as in-person session notes — using SOAP, DAP, BIRP, or another format — but include additional required elements specific to the telehealth modality.

The shift to telehealth expanded dramatically during the COVID-19 pandemic and has remained a permanent feature of mental health practice. With that permanence comes increased regulatory scrutiny. Payers, licensing boards, and auditors now expect telehealth documentation to meet specific standards that go beyond what is required for in-person notes. Clinicians who document telehealth sessions identically to in-person sessions risk denied claims, audit findings, and licensing board complaints.

The core difference is accountability for the remote environment. When a client is in your office, you control the clinical setting. When they are on a screen, you need to document that you verified the setting was appropriate, that the technology was adequate, that consent was in place, and that you had a plan for emergencies in the client's location.

When You Need It

Every time you conduct a therapy session via video or phone rather than in person
When an in-person session transitions to telehealth mid-appointment (e.g., client calls from their car after being unable to reach the office)
When insurance or Medicaid requires telehealth-specific documentation elements for reimbursement
When your state licensing board mandates specific telehealth documentation standards
When conducting crisis intervention remotely and you need to document the client's location for potential emergency dispatch
When providing services to a client who is in a different state under interstate compact or temporary practice provisions

Key Components

Standard Clinical Content

Your telehealth note should contain everything a regular progress note contains — presenting concerns, clinical observations, interventions used, assessment, and plan. The telehealth-specific elements are additions, not replacements.

Telehealth-Specific Documentation Elements

Modality and Platform: Document that the session was conducted via telehealth, the specific platform used, and whether it was audio-video or audio-only. If the session was audio-only, many states and payers require a clinical justification for why video was not used.

Client Location: Document the client's physical location at the time of the session — at minimum, the state. Best practice is to document city and state. This is legally required because your license to practice is jurisdiction-specific, and the client's location determines which state's laws apply.

Clinician Location: Some states require documentation of the clinician's location as well. Even where not required, documenting your location demonstrates regulatory compliance.

Informed Consent Verification: Document that telehealth-specific informed consent is on file. For the initial session, note the date consent was obtained. For subsequent sessions, a brief reference such as "Telehealth informed consent on file, dated [date]" is sufficient.

Privacy and Environment Confirmation: Document that you confirmed the client is in a private, confidential setting. Many clinicians ask at the start of each session: "Are you in a private location where you can speak freely?" Document the client's response.

Technical Adequacy: Note that the audio and video connection was adequate for clinical purposes, or document any technical difficulties that occurred and their impact on the session.

Emergency Plan: For telehealth clients, you should have the address of the client's current location and the contact information for local emergency services in the client's area. Document that this information is on file.

Observations Adapted for Telehealth

Documenting clinical observations via video requires acknowledging the limitations of the modality. You may not be able to assess psychomotor activity as fully through a screen, or you may not observe the client's full body language. Document what you can observe and note any limitations.

Filled-In Telehealth Session Example

Telehealth Session Note — CBT for Generalized Anxiety Disorder

Telehealth Details:

Platform: Doxy.me (HIPAA-compliant, BAA on file)
Client location: Portland, OR (client's home)
Clinician location: Portland, OR (private office)
Telehealth informed consent: On file, dated 01/07/2026
Client confirmed she is in a private room with the door closed
Audio and video quality: Adequate throughout session; no technical difficulties
Emergency contact and local crisis resources for client's location on file

S — Subjective: Client reports anxiety has been "more manageable" this week. States she used the worry time technique on four out of seven days and found it "actually helped — I didn't spiral as much at night." Reports one panic attack on Monday triggered by a work presentation, but states she was able to use diaphragmatic breathing and it "passed faster than usual — maybe 10 minutes instead of 30." Sleep has improved — reports falling asleep within 20 minutes most nights compared to 45+ minutes three weeks ago. Client states she cancelled a social dinner on Saturday due to anticipatory anxiety but expressed frustration about the avoidance: "I know I should have gone. I was mad at myself after." GAD-7 completed prior to session via patient portal: score 10 (moderate), down from 14 at session #8.

O — Objective: Client appeared on video from her home office. She was appropriately groomed, sitting upright, and made consistent eye contact with the camera. Affect was congruent and mildly anxious — observable fidgeting with a pen during discussion of the cancelled dinner. Speech was normal in rate and volume. Thought process was linear and organized. Client was engaged and actively participated in cognitive restructuring exercise targeting the thought "Everyone will judge me if I say something stupid at dinner." Client successfully identified the cognitive distortion (fortune telling, mind reading) and generated an alternative thought: "I've gone to dinners before and people responded positively. One awkward comment doesn't define how people see me." No psychomotor abnormalities observed within the limitations of video observation.

A — Assessment: Client continues to show meaningful progress in managing generalized anxiety symptoms, as evidenced by a GAD-7 decrease from 14 to 10 over four sessions and self-reported improvement in sleep latency and panic attack duration. The worry time intervention appears effective for reducing evening rumination. Client's ability to use diaphragmatic breathing during Monday's panic attack demonstrates growing skill generalization outside of session. Avoidance of the social dinner represents a continued area of difficulty — social avoidance remains the primary barrier to treatment goal #2 (increasing social engagement). Client's self-identified frustration about the avoidance suggests readiness to address this pattern more directly through behavioral experiments. Risk assessment: Client denied suicidal and homicidal ideation. No current safety concerns. Current diagnosis: Generalized Anxiety Disorder (F41.1). Prognosis: Good.

P — Plan:

Continue biweekly telehealth sessions (CBT)
Introduce graduated exposure hierarchy for social situations — begin developing hierarchy next session
Continue daily worry time practice (15 minutes, same time each day)
Assign behavioral experiment for the coming week: attend one social interaction of client's choosing and complete a thought record before and after
Continue GAD-7 monitoring via patient portal prior to each session
Next session: 04/01/2026 at 3:00 PM via telehealth

This is a sample for educational purposes only — not real patient data.

How to Write It Step by Step

Step 1: Confirm and document telehealth logistics at the start of the session. Before beginning clinical work, verify the client's location, confirm they are in a private setting, and note that informed consent is on file. Many clinicians build this into a brief check-in script they use at the start of every telehealth session.

Step 2: Note the platform and modality. Document the specific platform used and whether the session was audio-video or audio-only. If audio-only, document why. This takes one line but is required by most payers and licensing boards.

Step 3: Write your clinical note using your standard format. Use whatever progress note format your practice uses — SOAP, DAP, BIRP, or narrative. The clinical content standards are the same as for in-person sessions. Document the client's presentation, your interventions, your clinical assessment, and the plan.

Step 4: Adapt your observations for the telehealth modality. Be honest about what you can and cannot observe through a screen. You can document affect, eye contact, speech, grooming, and engagement. Note any limitations — for example, if the client's camera showed only their face, you could not assess psychomotor activity in their lower extremities.

Step 5: Document any technical difficulties. If the connection dropped, the video froze, or you had to switch to phone, document what happened, how long the disruption lasted, and whether it affected the clinical content of the session. If there were no issues, a brief note such as "audio and video adequate throughout" is sufficient.

Step 6: Include billing-specific elements. Note the Place of Service code, any required modifiers, and the CPT code. Telehealth billing errors are a common reason for claim denials, and documenting these elements in the note helps ensure consistency between the note and the claim.

Common Mistakes

Not documenting the client's location. This is the most common telehealth documentation error and the easiest to fix. Ask every session. Document every session. If the client is in a state where you are not licensed, you have a larger problem — but you cannot address it if you did not ask.
Omitting the platform name. "Session conducted via telehealth" is insufficient. Identify the specific platform and confirm it is HIPAA-compliant. Auditors and licensing boards want to see that you used an appropriate, secure platform.
Copying in-person observation language without adaptation. Writing "client presented to the office" when the client was on video is inaccurate. Similarly, documenting detailed observations about gait, psychomotor activity, or body language that you could not actually observe through a camera undermines your note's credibility.
Failing to document a plan for emergencies. If your telehealth client is in crisis, you need to know their exact location and the local emergency resources. Document that this information is on file and current. This is especially important for clients who travel or move between locations.
Not documenting when audio-only is used instead of video. Many payers reimburse audio-only sessions at a lower rate or require clinical justification. If you conducted a phone session, document why video was not used (client's internet was down, client was in a location without video capability, etc.) and confirm that the session was still clinically appropriate in audio-only format.