SOAP Notes for Telehealth
Master soap notes documentation in telehealth settings. This comprehensive guide covers specific requirements, compliance considerations, environment-specific documentation practices, and operational best practices for effective note-taking in telehealth practice.
Quick Answer
SOAP notes are a structured method for documenting telehealth sessions, consisting of Subjective, Objective, Assessment, and Plan sections. They must comply with HIPAA privacy rules and meet CMS documentation requirements to ensure legal and clinical standards are maintained. Accurate SOAP notes improve continuity of care and support reimbursement in telehealth settings.
Overview
This guide is part of our complete SOAP notes hub — format structure, a full clinical example, and all 72 diagnosis-specific templates.
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Short answer: a telehealth SOAP note uses the same four sections as an in-person note, plus a few telehealth facts. Record the modality (live video or audio-only) and the platform, where the client was during the session (the state, and an address or location you could send help to), where you were, who else was present or could hear, any technology problems that affected the session, and the emergency plan. Then document the clinical content as usual: Subjective (the client’s report), Objective (what you could observe on screen or hear, with scores), Assessment and Plan.
Why the extra facts matter: licensure generally follows where the client is located at the time of the session, emergency help has to be sent to the client’s actual location, and payers ask for the modality and place of service. Medicare and many other payers use place-of-service codes 02 (telehealth not in the patient’s home) and 10 (telehealth in the patient’s home) and modifiers such as 95 (live audio and video) or 93 (audio-only). Rules change and vary by payer and state, so check current requirements rather than relying on a template.
What to document in a telehealth SOAP note
| Item | What to document | Example wording |
|---|---|---|
| Modality and platform | Live video, audio-only, or a switch between them, and why | “50-minute session by live video on the practice’s telehealth platform; switched to phone for 6 minutes after video froze.” |
| Client location | State and a location you could send emergency help to, confirmed at the start | “Client confirmed she was at home in Ohio; address on file confirmed.” |
| Clinician location | Where you were, especially if your payer or policy requires it | “Clinician in private office.” |
| Privacy and others present | Whether the client could speak freely and who else was present or nearby | “Client alone in bedroom with door closed; partner at home in another room.” |
| Consent | Telehealth informed consent on file and any verbal consent required by state law or payer | “Telehealth consent signed at intake (on file); verbal consent confirmed today.” |
| Technology problems | Interruptions and whether they affected the assessment | “Video froze twice; risk questions repeated after reconnecting.” |
| Emergency plan | Emergency contact, nearest emergency services and what you will do if the call drops during a crisis | “Client’s address, local emergency dispatch number and emergency contact (sister) confirmed. If disconnected during a crisis, call the client back; if unreachable and emergency help is needed, contact dispatch serving the client’s location and the authorized emergency contact.” |
Safety on video and phone. Confirm the client’s location at the start of every session, not just at intake, because it can change. If a client reports suicidal thoughts, assess and record current thoughts, plan, intent, preparatory behavior, past attempts, access to means (including firearms and medications), protective factors, your risk formulation and the safety plan. Agree in advance what you will do if the connection drops during a crisis. The 988 Suicide & Crisis Lifeline takes calls and texts at 988; for imminent danger, call 911 or go to the nearest emergency department.
How to Document SOAP Notes for Telehealth
Subjective
Record the client's reported symptoms, concerns, mood, and perspective in their own words
When documenting the Subjective section in telehealth, focus on capturing the client’s self-reported symptoms, concerns, and emotional state as conveyed through the virtual interaction. This section should also note any reported environmental or situational triggers impacting the client’s condition.
- Client’s description of current symptoms and any changes since last session
- Identification of specific triggers or stressors reported during the telehealth session
- Client’s self-reported mood, affect, and emotional state observed through video or audio
- Any challenges or barriers the client reports related to the telehealth format (e.g., privacy, technology)
- Client’s feedback on how remote sessions are affecting their engagement or symptom management
Objective
Document clinical observations, affect, behavior, appearance, and measurable data
The Objective section for telehealth should document observable clinical data gathered remotely, including visual and auditory observations, use of telehealth-specific assessment tools, and any therapeutic techniques applied during the virtual session.
- Clinician’s observations of client’s appearance, posture, and nonverbal cues via video
- Documentation of client’s speech patterns, tone, and responsiveness during the session
- Use of telehealth-adapted assessment tools or screening instruments administered remotely
- Details of therapeutic modalities or interventions applied through telehealth (e.g., guided relaxation, cognitive exercises)
- Any technical issues encountered that may have impacted clinical observations or session flow
Assessment
Provide clinical interpretation, diagnostic impressions, and progress evaluation
In the Assessment section for telehealth, synthesize clinical impressions based on remote observations and client report, evaluating progress, diagnostic considerations, and client responsiveness within the telehealth context.
- Clinical interpretation of client’s symptom severity and functional status based on virtual interaction
- Evaluation of client’s engagement and responsiveness to telehealth interventions
- Consideration of telehealth’s impact on diagnostic clarity or symptom presentation
- Progress toward treatment goals as evidenced by client report and clinician observation during session
- Identification of any emerging concerns or changes in diagnosis requiring follow-up
Plan
Outline treatment strategy, interventions, homework, and follow-up schedule
The Plan section in telehealth should outline the next steps tailored to remote care, including treatment adjustments, homework assignments suited for telehealth, referrals, and scheduling of future virtual sessions.
- Scheduling of next telehealth appointment with consideration of client’s availability and technology access
- Assignment of remote-compatible homework or self-monitoring tasks to reinforce session objectives
- Modification of treatment approach or therapeutic modalities based on telehealth session findings
- Coordination of referrals to other remote or in-person services as appropriate
- Recommendations for improving telehealth session effectiveness, including technology or environment adjustments
Example SOAP note for a telehealth session
Fictional documentation example, not treatment guidance. Every detail is invented. Adapt it to the telehealth session you actually provided and your organization’s requirements.
Session details: Fictional adult client, 31, generalized anxiety disorder (F41.1), session 6. 50 minutes by live video on the practice’s telehealth platform; video froze at minute 22 and the session continued by phone for 6 minutes, then video resumed. Client confirmed at the start that she was at home in Ohio, alone in her bedroom with the door closed; partner home in another room. Clinician in private office, licensed in Ohio. Telehealth consent on file; verbal consent confirmed today. Emergency contact (sister) and address confirmed.
Subjective: Client reports worry “most of the day” about her job review next week, with trouble falling asleep (about 1 hour) on 5 of 7 nights. Practiced the worry-postponement exercise on 4 days and says it “helped on 2 of them.” Denies alcohol or drug use to manage anxiety.
Objective: GAD-7: 12 (moderate), down from 15 at session 3. On video: casually dressed, appropriately groomed; maintained eye contact with the camera; restless hand movements while discussing work; speech normal rate. Mood “on edge”; affect anxious, congruent. Thought process linear; no perceptual disturbances reported. Asked directly about suicidal thoughts after video resumed: denies thoughts of death or suicide, intent or plan; no past attempts.
Assessment: Generalized anxiety disorder with moderate symptoms, improving since session 3 (GAD-7 15 to 12) with partial use of worry postponement. Work review is the main current trigger. The 6-minute switch to phone limited observation of affect but not the risk questions, which were repeated on video.
Plan: Continue weekly 50-minute video sessions. Practice worry postponement daily and add a 10-minute wind-down routine before bed; client will log sleep onset. Next session: cognitive restructuring for predictions about the review. If the connection drops, clinician will call the client’s mobile. The emergency dispatch number serving the client’s confirmed address is on file; if the client is unreachable during a crisis requiring emergency help, clinician will contact that service and the authorized emergency contact. Client knows to call or text 988 in a crisis and to call 911 or go to the nearest emergency department for imminent danger.
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Tips for SOAP Notes for Telehealth
Confirm location every session
Record the state and a location you could send help to at the start of each session. Clients travel, and licensure and emergency response depend on where they are.
Name the modality
Write “live video” or “audio-only,” and note any switch. Payers often require it, and it affects what you could observe.
Record privacy
Note whether the client was alone and could speak freely. If not, say how that shaped the session.
Chart what the screen allowed
Describe only what you could see or hear. If the camera showed only the client’s face, do not chart gait or psychomotor activity you could not observe.
Document technology problems
Note interruptions and whether you repeated anything important, such as risk questions, after reconnecting.
Keep the emergency plan current
Confirm the emergency contact and what you will do if the call drops during a crisis, and record it.
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Further Reading
- HHS HIPAA — Provides essential guidelines on patient privacy and security requirements relevant to telehealth documentation.
- CMS Documentation Requirements — Outlines federal standards for clinical documentation necessary for telehealth billing and compliance.
- APA Documentation Guidelines — Offers detailed clinical documentation practices applicable to mental health professionals in telehealth.