Telehealth has become a permanent feature of mental health practice. What began as an emergency adaptation during the COVID-19 pandemic has evolved into a preferred modality for millions of clients and a standard service offering for most clinicians. But telehealth is not just in-person therapy delivered through a screen — it carries distinct documentation requirements that every clinician providing remote services needs to understand.
Document the Modality Explicitly
Every telehealth session note must explicitly state that the session was conducted via telehealth and specify the type. The primary modalities are:
**Synchronous video:** A real-time, two-way video session (e.g., via a HIPAA-compliant video platform). This is functionally most similar to in-person therapy and is reimbursed by most payers at the same rate as in-person.
**Audio-only (phone):** A real-time telephone session without video. Many insurers reimburse this separately, and some require specific billing codes. Your notes must reflect that this was phone rather than video.
**Asynchronous:** Communication that does not happen in real time (secure messaging, recorded video). This is less common in individual therapy but used in some behavioral health platforms.
Your documentation should state the modality clearly: "Session conducted via synchronous video telehealth" or "Session conducted via telephone (audio-only)" — not just "telehealth session."
Document the Platform and Its HIPAA Status
Note which platform was used for the session and confirm that it is HIPAA-compliant. You do not need to do this in every individual progress note, but it should be reflected in your informed consent documentation and your practice policies. If you change platforms, document the change.
Using a non-HIPAA-compliant platform (standard Zoom, FaceTime, Skype, or any consumer-grade video tool without a BAA) for telehealth therapy is a HIPAA violation. If you have been doing this, stop and transition to a compliant platform immediately. Commonly used HIPAA-compliant options include Doxy.me, SimplePractice's telehealth feature, TherapyNotes, and Zoom for Healthcare with a BAA.
Document Client Location — This Is Critical for Licensure
This is one of the most important and most overlooked telehealth documentation requirements: **you must document the client's location at the time of each telehealth session, specifically the state they are calling from.**
Why does this matter? Because your license authorizes you to practice in the states where you are licensed. If your client travels to another state and you provide therapy without being licensed there, you may be practicing without a license in that jurisdiction — which is a serious legal and ethical issue regardless of where you are physically located.
Documenting client location protects you. It creates a record that you knew where the client was and were authorized to practice there. For clients who travel frequently or live near state lines, this documentation is especially important.
A simple note in each session record: "Client confirmed location at session start: [City, State]" — takes seconds and provides important protection.
Document That Telehealth Informed Consent Was Obtained
Telehealth-specific informed consent goes beyond your general therapy consent. It should address: the nature and limits of telehealth services, technology risks (security, confidentiality limitations), what to do if the connection is interrupted, emergency procedures when the client is remote, and your state's specific telehealth informed consent requirements.
Document in the chart that the client received and acknowledged telehealth consent — typically at intake for ongoing telehealth clients, and whenever a new client begins services via telehealth. "Client reviewed and signed telehealth informed consent on [date]" in the intake documentation is sufficient.
Document Technical Difficulties and Their Clinical Impact
When technology fails during a telehealth session — connection drops, audio breaks up, video freezes — document it. Note what happened, for how long, how the session was managed (switched to phone, rescheduled, continued with partial video), and any clinical impact. If a significant technical disruption affected the session content or the client's experience, this is clinically relevant.
Example: "Session interrupted by 7-minute connection loss at approximately 25 minutes into session. Resumed via telephone. Client reported increased anxiety during the interruption. Processed the experience briefly before continuing with session goals."
Acknowledge the Limits of Telehealth Observation
Telehealth limits your clinical observation in ways you should be aware of and, in some cases, document. You cannot observe gait, tremors, or full body language. You may not be able to clearly assess a client's level of intoxication. A client's home environment is visible, which can provide useful context but also poses privacy considerations.
When clinically relevant, note the limits of your observation. If you are concerned about a client's physical state but cannot fully assess it via video, document that concern and what you did about it (called to check in, coordinated with prescriber, recommended in-person visit).
Emergency Protocols When the Client Is Remote
Every telehealth clinician must have documented emergency protocols for crises that arise when the client is not physically present. Your notes should reflect that you maintain this information and use it when needed.
Before initiating telehealth services with a client, obtain: their current physical address at the time of each session, a local emergency contact they consent to you reaching, and their local emergency services number (911 in the US, but different internationally). During a crisis situation, document what steps you took: whether you called emergency services, what information you provided, whether you reached the emergency contact, and the outcome.
If a client becomes acutely suicidal during a telehealth session and you are unable to reach them or emergency services, document every step you took in real time. The documentation of a crisis response is itself a protection and a demonstration of your professional standard of care.
Telehealth documentation, done correctly, is not significantly more burdensome than in-person documentation — it just requires attention to a handful of additional elements that reflect the realities of remote practice. Build these into your templates and they become automatic.