What should a telehealth visit documentation include?

• A. Document visits and risk assessments, including patient identity verification and emergency plan.
• B. Document only the duration of the call.
• C. Do not document risk assessments.
• D. Document call quality metrics.

Answer: (A)

In telehealth, documentation must capture safety, continuity, and accountability. The best practice is to record the visit details along with a risk assessment, and to include verification of the patient’s identity and an emergency plan. Verifying identity is essential in remote care to ensure you are treating the correct person and to protect privacy and accuracy in the medical record. An emergency plan is critical because issues can arise during or after a telehealth session, and you need clear steps and local crisis resources or emergency contact information based on the patient’s location. A risk assessment is necessary since telehealth may limit in-person observation; it helps identify safety concerns such as suicidality, risk of harm to others, or challenges in following the treatment plan, enabling timely safety planning, referrals, or escalation.

Documenting only the call duration misses key clinical and safety information. Not documenting risk assessments neglects patient safety, and recording call quality metrics focuses on service delivery rather than the patient’s clinical needs.