The Five Facts Every Teletherapy Note Has to Capture

Pull up your last teletherapy note and read it next to an in-person note from the same week. If you cannot tell which one was the video session, that is not a sign of consistency — it is a gap. The clinical content is supposed to be identical. But a teletherapy visit generates facts an in-person visit does not: what technology carried the session, where each party physically was, what the patient agreed to, and who else was in the room on either end. When those facts are missing, the note is fine right up until someone other than you reads it — a payer auditing telehealth claims, a licensing board asking whether you were authorized to treat a patient in another state, or a reviewer deciding whether an audio-only session was billable at all.

This article covers the telehealth layer of a therapy note: the five facts that make a record defensible as a telehealth record, the Medicare billing fields that have to agree with the note, and a pre-signature checklist that takes seconds once the habit exists. It is written for speech, occupational, and physical therapists, and it leans on Medicare’s published rules because Medicare writes them down — but the through-line is that telehealth policy is unusually unstable, and the second half of the discipline is knowing which of these rules to re-verify, and when.

Start with what does not change, because it is most of the note. ASHA’s Medicare telehealth guidance is explicit that clinicians report the same CPT codes and follow the same coding guidelines for telehealth services as for in-person services, and the same logic runs through the documentation: the skilled-care reasoning, the objective data, the response to intervention, and the plan all have to be there, held to the same standard a reviewer would apply to any visit. A teletherapy note is not a different kind of note. It is the same note with a telehealth layer added — and both halves can sink a claim independently. A note with perfect telehealth fields and no skilled-care reasoning fails as clinical documentation; a clinically excellent note with no record of modality, location, or consent fails as a telehealth record.

That framing matters because the common failure mode runs the other way. Most therapists already write clinically defensible notes; the telehealth layer is what gets skipped, precisely because it feels administrative. The rest of this article is that layer.

Each of these five is a single line in the note, and each answers a question someone with authority may eventually ask. None of them is clinical judgment; all of them are evidence. Build them into the template so they cannot be skipped on a busy day.

1. 01

   Modality: audio-video or audio-only

   State how the session was delivered — real-time audio-video, or audio-only. This is not a formality: under Medicare the modality determines which claim modifier applies (95 for audio-video, 93 for audio-only), and audio-only is billable for a patient at home only under specific conditions. ASHA’s documentation guidance likewise calls for recording the location and manner of service delivery — in person or via telepractice — as part of the basic record of the session.

2. 02

   Platform: what carried the session

   Record the platform or technology used. Since the HIPAA enforcement discretion that covered improvised video tools during the COVID-19 public health emergency expired in May 2023, telehealth in a covered practice has to run on a setup that complies with the HIPAA Rules — for most practices that means a vendor that will sign a business associate agreement. Naming the platform in the note ties the session to that compliant setup, and a mid-session technology failure belongs here too: if the visit dropped and reconnected, the note should say so, because interrupted time matters wherever billing is time-based.

3. 03

   Locations: where the patient was, and where you were

   Document the patient’s physical location at the time of service — at minimum the setting and state — and your own. The patient’s location is the load-bearing fact of the whole note: it generally determines which state’s licensure rules apply, it drives the Medicare place-of-service code, and it is the fact most likely to change without warning. A family on vacation, a college student home for the summer, a snowbird patient — each is a licensure question that the note either answers or hides.

4. 04

   Consent: what the patient agreed to

   Document that the patient (or guardian) consented to receiving services via telehealth, after an explanation of how it works and its limits. Whether telehealth-specific informed consent is legally required, in what form, and how often varies by state — and where requirements differ across the states involved, ASHA’s telepractice guidance encourages following the most restrictive of them. A one-line entry with a date — verbal consent obtained, or signed form on file — converts the consent from something that happened into something that exists.

5. 05

   Participants: everyone present on both ends

   Name everyone who was present or assisted on either side of the call: a parent facilitating a pediatric session, an aide positioning materials, a caregiver observing, a sibling in the room. This documents who received any training you delivered, supports the privacy conversation if PHI was discussed within earshot of others, and — in pediatric teletherapy especially — records the facilitator whose participation the treatment actually depended on.

For Medicare Part B, the telehealth facts in the note map directly onto claim fields, which means the note is the evidence behind the billing. Under the current flexibilities, extended by the Consolidated Appropriations Act of 2026 through December 31, 2027, PTs, OTs, SLPs, and audiologists can furnish Medicare telehealth services as distant-site practitioners, patients can be seen in their homes, and there are no geographic restrictions for non-behavioral-health telehealth. Three fields do the work on the claim, and each one is answerable only from the note.

The audio-only rule is a documentation rule

Audio-only deserves its own paragraph because the billing permission is itself a documented circumstance. Under CMS’s current definition of an interactive telecommunications system, a telehealth service to a patient at home may be furnished by two-way, real-time audio-only technology when the practitioner is technically capable of using audio-video and the patient either is not capable of using video or does not consent to it. Every clause of that sentence is a fact about the session. A phone session note that says only “session held by phone” has not established that the session was billable; a note that says the practice’s video platform was available, and that the patient could not join by video — no compatible device, no adequate connection, or a stated preference against video — has. If a session that started on video dropped to audio partway through, record that too, with the time split.

The reason the location line is non-negotiable is that it decides which rules govern the session. As a general matter, treating a patient located in another state implicates that state’s practice act — ASHA’s telepractice guidance directs clinicians to check the practice requirements of both their own state and the state where the client is located before engaging in interstate telepractice, and the licensure compacts now in various stages of implementation for audiology and speech-language pathology, occupational therapy, and physical therapy each have their own membership and privilege mechanics. None of that can be resolved inside a note — but the note is where the fact that raises the question gets recorded. A note that documents “patient participated from home in [state]” at every session creates the record that licensure was knowable, and a location change becomes a flag you catch at the next session instead of a surprise in an audit.

Consent has the same shape. Whether a state requires telehealth-specific informed consent, whether it must be written or may be verbal, and how often it must be refreshed are all state-level questions, layered under any payer-specific consent rules. Where the states involved answer differently, ASHA encourages following the most restrictive applicable requirement. The documentation practice that survives all of these variations is the simplest one: obtain consent before the first telehealth session, record it with a date and form, and re-confirm it when something material changes — a new guardian, a new modality, a new state.

During the COVID-19 public health emergency, HHS’s Office for Civil Rights exercised enforcement discretion that let providers deliver telehealth in good faith over everyday video tools without HIPAA penalties. That discretion expired on May 11, 2023, with a transition period that ended that August. Since then, telehealth in a HIPAA-covered practice has to run on an arrangement that complies with the HIPAA Privacy and Security Rules — in practice, a platform vendor that will sign a business associate agreement, configured so that sessions and any recordings are protected. OCR has also published guidance specifically on using remote communication technologies for audio-only telehealth, which is worth reading before assuming a plain phone call raises no privacy questions at all.

For the note itself, the platform line carries two jobs. It ties the session to the practice’s compliant setup, and it is where session-integrity problems get recorded: the connection that dropped twice, the video that froze and forced a switch to phone, the caregiver who could not get audio working for the first five minutes. Those details protect you in both directions — they explain a shortened or fragmented session honestly, and where billing is time-based, they are the difference between a defensible time entry and an approximation.

Here is what the telehealth layer looks like in a real-shaped note — not a new document, just a short block above the clinical content that would be there anyway. The case is fictional.

Run this before signing any teletherapy note. The first five items are the telehealth layer; the last three keep the layer connected to the billing and the clinical record. With the template block in place, the whole pass takes seconds.

The best recent argument for this section is what happened over four days in early 2026. Medicare’s telehealth flexibilities — including therapists’ eligibility to furnish telehealth at all — lapsed when their statutory authority expired at the end of January 30, 2026. On February 3, 2026, the Consolidated Appropriations Act, 2026 extended them through December 31, 2027. Practices that treated “Medicare covers teletherapy” as a settled fact briefly ran sessions with no coverage authority in place; practices that tracked the expiration date saw it coming months out. Neither AOTA, APTA, nor ASHA regards the current extension as the end state — all three are advocating for permanent authority — which means the same cliff is scheduled to reappear.

The operational fix is small: keep a short list of the telehealth rules your practice depends on — Medicare authority, each major payer’s telehealth policy, each state’s consent and licensure rules you practice across, and your platform’s BAA — and attach to each one the date it expires or was last confirmed. Review the list quarterly and before onboarding any patient in a new state. It is the difference between a policy change being a calendar item and being a revenue event.