Telehealth Visit Documentation Audit

Audit template for verifying telehealth visit documentation, including consent, technology readiness, identity verification, and required time elements.

Audit Details

• Encounter date and time reviewed
  Document the date/time of the telehealth encounter or the chart review date if the encounter timestamp is not available.
• Encounter identifier documented
  Record the visit/encounter ID, chart number, or other unique identifier used to locate the record.
• Rendering provider documented
  Provider name and credentials are documented in the note.
• Audit reviewer completed
  Reviewer signature confirming the audit was completed.
• Audit scope identified
  Select the type of telehealth documentation reviewed.

Patient Identity and Consent

• Patient identity verified at start of visit
  Documentation shows the patient identity was verified using at least two identifiers or other approved verification method.
• Patient consent for telehealth documented
  The note documents informed consent for telehealth services before or at the time of the encounter.
• Consent includes modality and limitations
  Consent documentation reflects the telehealth modality used and any relevant limitations or risks discussed.
• Patient location documented when required
  The patient’s physical location at the time of service is documented when required by policy, payer, or state law.
• Emergency contact or escalation plan documented when required
  The record includes an emergency contact, local emergency plan, or escalation instructions when required for the encounter type.

Technology Readiness and Visit Modality

• Telehealth platform or modality documented
  Document the platform, application, or communication method used for the visit.
• Connection readiness confirmed
  The note indicates the technology was functioning adequately to complete the visit (audio/video quality, connection stability, or equivalent).
• Backup plan or technical issue documented when applicable
  If there were technical problems, the note documents the issue and any backup plan, rescheduling, or conversion to another modality.
• Privacy environment addressed
  The documentation indicates the visit was conducted in a private or appropriate environment to support confidentiality.
• HIPAA-compliant communication method documented when applicable
  If relevant, the record identifies the communication method and any compliance considerations for the telehealth encounter.

Required Time Elements

• Start time documented
  The encounter note includes the visit start time when required by payer or policy.
• End time documented
  The encounter note includes the visit end time when required by payer or policy.
• Total time documented
  Total time spent on the encounter is documented in minutes.
• Time supports billed service level
  Documented time is consistent with the billed service level and applicable telehealth billing rules.
• Time-based counseling or care coordination documented when applicable
  If time-based coding was used, the note supports the amount of time spent on counseling, coordination, or other billable activities.

Documentation Quality and Exceptions

• Assessment and plan documented
  The note includes a clear assessment and plan appropriate to the telehealth encounter.
• Medical decision-making or clinical rationale documented
  The documentation supports the clinical reasoning or decision-making for the encounter.
• Any documentation deficiencies identified
  Select all deficiencies found during the audit.
• Corrective action required
  Indicate whether follow-up, education, addendum, or chart correction is needed.
• Audit result
  Overall audit outcome based on the reviewed documentation.