News & Insights

Documentation Recommendations for Patient’s Consent to Telemedicine Visits

March 27, 2020

Amy M. Winters, Attorney at Law, Partner, Jones Walker LLP, and John R. Dildy, MBA, J.D., LL.M, Assistant General Counsel, LAMMICO


During this public health emergency, states are issuing emergency rules on what constitutes telemedicine and what should be documented. When conducting telemedicine consultations, physicians should look to the patient’s state for guidance on the rules for telemedicine and the requirements for licensure and documentation.

For example, physicians in Louisiana participating in telemedicine visits with their Louisiana patients follow the rules in Louisiana. Louisiana telemedicine visits are recommended for all patients when they are medically appropriate and when the same standard of care can be met as an in-person visit.

In addition to documenting the care you provided to the patient, the following should also be included in your documentation of the telemedicine visit: 

  • The patient understands (i) the current public health orders, (ii) that telemedicine visits are allowed during the emergency period, and (iii) that the patient has the right to choose the telemedicine encounter, and may withdraw from this mode of care at any time.

  • The patient has been provided with contact information for the provider in the event of technical difficulties during the encounter, if they may be needed for follow-up or emergency care, or to obtain the provider’s medical records. 

  • The provider’s medical opinion that the delivery of healthcare services via telemedicine is consistent with the standard of care for an in-person visit, and is medically appropriate. The provider should note any limitations or restrictions to the visit. Examples of limitations or restrictions include:

    • That no physical examination was performed

    • That no peripherals such as otoscope or stethoscope were used

    • That certain vitals (such as blood pressure) were obtained through patient reports, observations, and/or measurements

  • The patient has verbally consented to proceed with services via telemedicine and the provider was able to complete the telemedicine visit without complication to the satisfaction of the physician and the patient. Below are two examples:

Sample Documentation of Video Consultation

The patient was informed of the restrictions of face-to-face healthcare visits due to the COVID-19 pandemic. On [insert date], the patient verbally consented to proceed with a telemedicine visit, following discussion of the options of face-to-face or telemedicine visits. The telemedicine visit was completed using [insert whichever program you use] without complication. The visit was conducted without physical exam and was medically appropriate to meet the patient’s needs. [Insert recommendations or referrals (if any), including emergent/urgent face-to-face visits or diagnostic testing as appropriate]. I provided the patient with contact information for follow-up care. 

Sample Documentation of Audio Consultation

The patient was informed of the restrictions of face-to-face healthcare visits due to the COVID-19 pandemic. On [insert date], the patient verbally consented to proceed with a telemedicine visit, following discussion of the options of face-to-face or telemedicine visits. The telemedicine visit was completed by telephone without complication. The visit was conducted without physical exam and was medically appropriate to meet the patient’s needs. [Insert recommendations or referrals (if any), including emergent/urgent face-to-face visits or diagnostic testing as appropriate]. I provided the patient with contact information for follow-up care.

Other considerations:

  • If interruptions in or barriers to the delivery of services via telemedicine occur, document the nature and extent of the complication (e.g., disconnected or interrupted service), as well as the follow-up by the provider to ensure continuity of care.
  • If a patient elects a face-to-face visit, document the discussions with the patient of the risks including the delay of such visit for the duration of the public health emergency and the implications for ongoing care. 

Sample Documentation of Declined Telemedicine Consultation

The patient was informed of restrictions of face-to-face healthcare visits due to the COVID-19 pandemic. After discussions about both telemedicine and face-to-face visits, the patient verbally declined to proceed with a telemedicine encounter, and elected to proceed with a face-to-face visit after the public health crisis. I provided the patient with contact information in the event of a change or worsening of their condition or other emergent/urgent needs. I also provided the patient with appropriate instructions and prescriptions [if applicable] for care to be continued in the interim as well as information in case the patient later elects to proceed with a telemedicine visit.

These examples do not constitute an endorsement, certification, or recommendation of specific technology, software, applications, or products. 

While other states may have similar rules, please confirm with the state where telemedicine is occurring for licensure requirements and specific guidance on using audio and video telemedicine technology. 

For documentation recommendations for healthcare services and medical and surgical procedures, please visit click here

Additionally, consult the recent HHS OCR Notification of Enforcement Discretion and subsequent Guidance (FAQs) on Telehealth and HIPAA during the COVID-19 nationwide public health emergency. Among the issues discussed in the FAQs, are acceptable and unacceptable forms of remote communication when providing telehealth. The Notification may be found here and the FAQs here.  

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