What are three examples of documentation needed for a telehealth visit?

Asked by: Dr. Elvis Johnston  |  Last update: June 13, 2025
Score: 4.6/5 (71 votes)

To ensure appropriate payment, the following documentation elements should be captured for a telehealth visit (7,13): ❖ Date of the visit. ❖ Consent for visit from patient or patient representative (verbal or written). ❖ Category for office visit—real-time audio with video or audio/telephone only.

What documentation is necessary to include for a telehealth visit?

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 photo ID close to the camera.

What are the three components of telehealth?

There are three main types of telemedicine, which include store-and-forward, remote monitoring, and real-time interactive services. Each of these has a beneficial role to play in overall health care and, when utilized properly, can offer tangible benefits for both healthcare workers and patients.

What are 3 specific examples or uses of telemedicine?

Benefits of Telemedicine
  • Control of Infectious Illness. To help prevent the spread of COVID-19, flu and other infectious diseases, doctors can use telehealth appointments to prescreen patients for possible infectious disease. ...
  • Better Assessment. ...
  • Family Connections. ...
  • Primary Care and Chronic Condition Management.

What are the five basic requirements for telemedicine?

The Five Elements of Compliant Telehealth Services
  • Policies and Procedures. ...
  • Scope of Services. ...
  • Safe Communication Method(s) ...
  • Consent. ...
  • Accurate Documentation.

Telehealth Established Patient Documentation

19 related questions found

What qualifies as a telemedicine visit?

Telehealth, sometimes referred to as telemedicine, is the use of electronic information and telecommunications technologies to extend care when you and the patient aren't in the same place at the same time.

What are the telehealth guidelines for 2024?

Before the COVID-19 PHE, patients needed to get telehealth at an originating site located in a certain geographic location. Through December 31, 2024, all patients can get telehealth wherever they're located. They don't need to be at an originating site, and there aren't any geographic restrictions.

How does a telehealth appointment work?

The telehealth appointment is similar to what would happen in a face-to-face medical consultation. Your doctor will ask about your condition, symptoms, medical history and more. Based on your discussion, he/she may prescribe medicine or recommend potential tests, procedures or other treatment options.

Which of the following is an example of telehealth?

Examples of telehealth includes health education services, remote monitoring of vital signs, ECG or blood pressure and remote doctor-patient consultations (telemedicine).

Which of the following observations should not be included in a patient's medical record?

Final answer: The observation that should not be included in a patient's medical record is the notes regarding the patient's participation in a rally, as it is not directly relevant to their health.

What are the 4 P's of telehealth?

Approach. We developed and implemented a telehealth blueprint to enhance telehealth content within our clinical Doctor of Nursing Practice (DNP) program guided by the Four Ps of the Telehealth Framework planning, preparing, providing, and performance evaluation.

What devices are needed for telehealth?

For most telehealth visits, you need a device that has video and sound. This could be a computer, smartphone, or tablet.

What are the three major ways telehealth services are delivered?

Telehealth can be divided into three major modalities: real-time, store-and-forward (asynchronous), and remote patient monitoring.

What are the four features of documentation involved in managing risk in telehealth?

The correct answer is that the four features of documentation involved in managing risk are Completeness, Consistency, Traceability, and Verifiability. Documentation is a critical component in managing risk within any project or organization.

What must be included in patient record documentation?

Each Medical Record shall contain sufficient, accurate information to identify the patient, support the diagnosis, justify the treatment, document the course and results, and promote continuity of care among health care providers.

Does time have to be documented for telehealth visits?

Document Time Spent: For billing, document the total time spent on the encounter, including start and stop times if telehealth-specific or list total time on the encounter date if other activities related to the patient and/or medical decision making are involved.

What qualifies as a telehealth visit?

What does telehealth mean? Telehealth — sometimes called telemedicine — lets you see your health care provider without going to their office. You can have a telehealth visit online using your computer, tablet, or smartphone.

What are the three types of telehealth?

The 3 types of telemedicine services are synchronous, asynchronous, and remote monitoring. Synchronous refers to the delivery of health information in real time. This allows for a live discussion with the patient or provider to deliver medical expertise.

What are 2 examples of telehealth?

Examples include:
  • Video calls between a patient and a health care provider.
  • Audio only calls when a video visit is not an option.
  • Secure text messaging to answer patient questions.

What should be done before a telehealth visit?

What should I do before a video visit?
  • Adjust lighting. Make sure your health care provider can clearly see you.
  • Steady camera. Keep your device stable. ...
  • Be centered. Sit so your face is in the middle of the screen and the camera is at the same height as your eyes. ...
  • Check sound. ...
  • Close extra stuff.

Do they call you at telehealth appointments?

A Kaiser Permanente doctor or nurse will call you to start your visit. From there, it's just like an in-person visit — without the exam room. The doctor or nurse will diagnose and treat your health concerns, work with you to create a personalized care plan, and prescribe medication as needed.

Do doctors record telehealth visits?

Your telehealth visits should not be recorded. The only information that is saved are notes that your health care provider writes in your private health record.

How to document a telehealth visit?

Telemedicine Documentation Guidelines
  1. Telehealth Platform: Document in a patient's medical record which method of telemedicine was used. ...
  2. Remote Location: Make sure to note where the patient is physically located. ...
  3. Informed Consent: Be sure to obtain consent from a patient before initiating a telemedicine appointment.

Does telehealth write doctor's notes?

Our 24/7 virtual care telehealth service provides online doctor's notes in minutes for work, school, or travel. Easy, convenient, and confidential consultations from the comfort of your home using your tablet, computer or phone. For: Anyone, ages 18 or older, under 18 must have adult present.

How long is a telehealth appointment?

A telehealth visit usually lasts about 10 minutes, but it can run longer if needed.