Virtual Care Documentation Best Practice

November 5, 2020

With increasing reliance on virtual care, providers should be conscious of the documentation requirements for a virtual care service to be compliant with CMS standards. Virtual care documentation requirements are similar to a face-to-face encounter, but include four additional elements:

1. Statement indicating the telehealth service was provided using both audio and video modalities
2. Location of the patient and the location of the provider
3. Names of additional persons participating in the telemedicine visit and their role in the visit
4. A statement indicating patient consent was given for the telehealth visit

For more information and examples of best-in-class documentation, review this guide.