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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.

Note (optional)

Encounter identifier documented

Record the visit/encounter ID, chart number, or other unique identifier used to locate the record.

Rendering provider documented critical (required)

Provider name and credentials are documented in the note.

Audit reviewer completed critical (required)

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 critical (required)

Documentation shows the patient identity was verified using at least two identifiers or other approved verification method.

Yes No N/A

Patient consent for telehealth documented critical (required)

The note documents informed consent for telehealth services before or at the time of the encounter.

Yes No N/A

Consent includes modality and limitations

Consent documentation reflects the telehealth modality used and any relevant limitations or risks discussed.

Yes No N/A

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.

Yes No N/A

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.

Yes No N/A

Technology Readiness and Visit Modality

Telehealth platform or modality documented

Document the platform, application, or communication method used for the visit.

Connection readiness confirmed critical (required)

The note indicates the technology was functioning adequately to complete the visit (audio/video quality, connection stability, or equivalent).

Yes No N/A

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.

Yes No N/A

Privacy environment addressed

The documentation indicates the visit was conducted in a private or appropriate environment to support confidentiality.

Yes No N/A

HIPAA-compliant communication method documented when applicable

If relevant, the record identifies the communication method and any compliance considerations for the telehealth encounter.

Yes No N/A

Required Time Elements

Start time documented critical (required)

The encounter note includes the visit start time when required by payer or policy.

End time documented critical (required)

The encounter note includes the visit end time when required by payer or policy.

Total time documented critical (required)

Total time spent on the encounter is documented in minutes.

Time supports billed service level critical (required)

Documented time is consistent with the billed service level and applicable telehealth billing rules.

Yes No N/A

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.

Yes No N/A

Documentation Quality and Exceptions

Assessment and plan documented

The note includes a clear assessment and plan appropriate to the telehealth encounter.

Yes No N/A

Medical decision-making or clinical rationale documented

The documentation supports the clinical reasoning or decision-making for the encounter.

Yes No N/A

Any documentation deficiencies identified

Select all deficiencies found during the audit.

Note (optional)

Corrective action required critical (required)

Indicate whether follow-up, education, addendum, or chart correction is needed.

Yes No N/A

Audit result critical (required)

Overall audit outcome based on the reviewed documentation.

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Run: Telehealth Visit Documentation Audit

Audit Details

Patient Identity and Consent

Technology Readiness and Visit Modality

Required Time Elements

Documentation Quality and Exceptions

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