Guide

The teletherapy note: location, consent, modality

Summary

A teletherapy note needs everything an in-person note needs, plus three additions: the client's physical location at the start of the session, since it determines which state's rules applied; confirmation that telehealth-specific informed consent was covered; and the platform and modality used, video or audio-only, since that affects which codes are payable. Nothing about the clinical content itself changes — SOAP, DAP, or BIRP still organizes it the same way.

By Gale Editorial · Updated 2026-07-26. Every figure cited to a dated source. How we write.

What a teletherapy note needs beyond the ordinary note

A teletherapy note carries the same clinical content as an in-person note — whatever your format, SOAP, DAP, or BIRP still organizes it the same way — plus three additions specific to the modality: where the client was located, that telehealth-specific consent was addressed, and what platform and modality were actually used. None of the three additions changes the clinical substance of the note; they document the circumstances the session happened in.

Solo practices sometimes treat telehealth as requiring an entirely separate documentation template, which adds friction without adding useful information. The simpler approach is to keep your existing note format and add these three elements as a standing habit at the start of every remote session, the same way you would note the room number for an in-person visit.

Skipping these additions is the most common telehealth documentation gap, not because clinicians don't know the information — they usually do — but because it lives in a scheduling system or an intake form rather than in the session note itself, where a reviewer actually looks.

Document the client's location — it decides which jurisdiction applied

Record the state the client was physically located in at the start of every telehealth session, not just the state where you are licensed, because the client's location is generally what determines which jurisdiction's practice laws and consent requirements governed that specific session. Telepsychology-specific practice guidance treats this interjurisdictional question as a standing competence issue, not a one-time credentialing check 1Ref 1American Psychological Association (2013).Guidelines for the Practice of Telepsychology.That the client's physical location and the interjurisdictional question it raises is a standing telehealth competence issue to document every session..

This matters most for a client who travels, attends school out of state, or splits time between two residences — a client physically in a different state than the one where you normally see them may put you outside your licensure unless that state has a specific telehealth or reciprocity provision. Document the location you confirmed, not an assumption based on the client's home address on file.

If a client's location changes mid-treatment, note it explicitly and address whether continuing care from that location is permissible under your license before the next session, not after a gap has already occurred.

The platform and modality belong in the note

Name the platform you used and confirm it operates under a signed business-associate agreement, since telehealth is now expected to run on HIPAA-compliant arrangements with the pandemic-era enforcement discretion no longer in effect — a note that states the platform used, briefly, gives you a contemporaneous record that you were using an appropriate tool at the time 3Ref 3HHS Office for Civil Rights (2026).HIPAA and Telehealth.That telehealth must run on HIPAA-compliant, business-associate-agreement-covered arrangements now that COVID-era enforcement discretion has ended..

If you use an AI transcription or scribing tool as part of the session, document that separately and confirm the client consented to it — ai scribes in the therapy room raise their own consent and vendor-agreement questions distinct from the video platform itself, and folding that disclosure into the general platform note is not sufficient.

Note any technical disruption that materially affected the session, such as a dropped connection that cut a session short, or a shift from video to phone partway through, and document it as distinct from missed sessions entirely — a dropped call is not a no-show, and the note should make that distinction explicit.

Audio-only vs video: what payers need documented

State plainly whether the session was conducted by video or audio-only, since payers determine reimbursement eligibility partly on that distinction, and CMS publishes the definitive annual list of which codes are payable via telehealth and which specifically allow audio-only delivery 4Ref 4Centers for Medicare & Medicaid Services (2026).List of Telehealth Services.That which codes are payable via telehealth, and via audio-only specifically, is set by CMS's published list, supporting the need to document modality.. A note silent on modality forces a biller to guess, and guessing wrong on an audio-only claim is a preventable denial.

This single line — video or audio-only — is cheap to write and expensive to omit, since it is exactly the detail a payer's utilization reviewer or your own biller needs when a claim is questioned. Make it a standing first line of every telehealth note, not an afterthought only added when a claim gets denied.

If your state or a specific payer treats audio-only sessions differently for parity or coverage purposes, that distinction is one more reason the modality line needs to be explicit and consistent, not implied by the session's billed code alone.

Where the note lives, and what a hybrid practice needs to keep straight

Keep the teletherapy note in the same general record as your in-person notes — there is no separate telehealth-specific record category under HIPAA, and the carve-out that excludes assessment, plan, and progress content from psychotherapy notes applies identically regardless of modality 5Ref 5HHS Office for Civil Rights (2026).Does HIPAA provide extra protections for mental health information compared with other health information?.That the psychotherapy-notes carve-out applies the same way regardless of whether a session happened by telehealth or in person.. A hybrid practice mixing in-person and remote sessions for the same client should read as one continuous chart, not two parallel ones.

The golden thread, the continuous line from assessment through intervention to outcome, should run through a hybrid chart the same way it runs through an all in-person one; a reviewer should not be able to tell, from the clinical content alone, which sessions happened over video. Record-keeping guidance for the field does not carve out a separate standard for telehealth content 6Ref 6American Psychological Association (2007).Record Keeping Guidelines.That record-keeping content standards do not carve out a separate, lesser standard for telehealth-delivered sessions..

If you switch a client between modalities mid-treatment, document why, such as a scheduling conflict, a client preference, or a weather event, the same way you would document any other change in the course of care, so the modality shift reads as a decision rather than an unexplained gap.

If a crisis happens over video, not in the room

A crisis surfacing over telehealth needs the same structured response as one in the office — the crisis note that documents it should show what you assessed, what you did given that you were not physically present, and how you would reach emergency services for that client's specific location. Structured safety planning intervention does not change form because the session happened remotely 7Ref 7Stanley B, Brown GK (2012).Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk.That structured safety planning intervention documentation applies the same way whether a crisis surfaces in person or over telehealth..

Confirm and document the client's physical address at the start of any session where a crisis is a live possibility, precisely because you may need to direct local emergency responders there. This is the sharpest version of the location-documentation habit from earlier in this note, and it is worth restating because it is the one piece of telehealth documentation with the highest stakes if it is missing.

If a technical disruption happens during a crisis-relevant session, such as a dropped call at a bad moment, document what you tried, in what order, and how the session or the safety response ultimately resolved, since that sequence is exactly what a reviewer will want to see afterward.

Common questions

No. Keep your existing SOAP, DAP, or BIRP format and add three standing elements: the client's physical location, confirmation that telehealth-specific consent was covered, and the platform and modality used. The clinical content is documented the same way regardless of whether the session happened in person or over video.

Document the location you confirmed, since the client's physical location generally determines which state's practice laws applied to that session. If a client is temporarily in a state where you are not licensed, address whether continuing that specific session is permissible before it happens, not after the fact.

State plainly whether the session was video or audio-only, since payers determine reimbursement eligibility partly on that distinction and audio-only eligibility varies by code. A note silent on modality leaves your biller guessing, which is a preventable source of denied claims.

Document it once, at the start of telehealth care, in the general record rather than a separate file, confirming that platform security, connection failures, and remote crisis response were discussed. Reference it briefly again only if the platform or your emergency protocol changes.

Yes. Document the client's consent to the scribing tool separately from the platform note, since it raises its own vendor-agreement and disclosure questions distinct from the video platform itself. Treat it as its own line in the note, not an assumed part of the general telehealth consent.

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References

1.American Psychological Association (2013). Guidelines for the Practice of Telepsychology. American Psychological Association. linkThat the client's physical location and the interjurisdictional question it raises is a standing telehealth competence issue to document every session.
2.American Counseling Association (2014). ACA Code of Ethics. American Counseling Association. link ✓That distance-counseling informed consent is its own distinct content, separate from ordinary informed consent, that the note should confirm was covered.
3.HHS Office for Civil Rights (2026). HIPAA and Telehealth. U.S. Department of Health and Human Services. linkThat telehealth must run on HIPAA-compliant, business-associate-agreement-covered arrangements now that COVID-era enforcement discretion has ended.
4.Centers for Medicare & Medicaid Services (2026). List of Telehealth Services. Centers for Medicare & Medicaid Services (CMS). link ✓That which codes are payable via telehealth, and via audio-only specifically, is set by CMS's published list, supporting the need to document modality.
5.HHS Office for Civil Rights (2026). Does HIPAA provide extra protections for mental health information compared with other health information?. U.S. Department of Health and Human Services. linkThat the psychotherapy-notes carve-out applies the same way regardless of whether a session happened by telehealth or in person.
6.American Psychological Association (2007). Record Keeping Guidelines. American Psychological Association. link ✓That record-keeping content standards do not carve out a separate, lesser standard for telehealth-delivered sessions.
7.Stanley B, Brown GK (2012). Safety Planning Intervention: A Brief Intervention to Mitigate Suicide Risk. Cognitive and Behavioral Practice. linkThat structured safety planning intervention documentation applies the same way whether a crisis surfaces in person or over telehealth.

https://www.gale.care/for-providers/bhd-telehealth-session-documentation · 7 sources. Competitor details are cited to dated public sources and maintained as they change; figures are estimates, not commitments. Synthetic demonstration.

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