Telehealth Documentation Best Practices for AI Scribes

Telehealth has become a permanent fixture in medical practice. AI documentation for virtual visits requires some different considerations than in-person encounters. Here's how to optimize your telehealth documentation workflow.

Technical Setup for Telehealth Recording

Audio quality is even more important for telehealth because you're relying on the video call audio:

• Use a quality headset with a microphone for clearer audio
• Ensure your AI scribe can capture system audio (not just microphone)
• Test your setup before the first visit of the day
• Have a backup plan if audio quality is poor
• Consider using the AI scribe mobile app to capture separately

Patient Consent for Telehealth Recording

The consent conversation works similarly to in-person visits, but mention that you're using AI to document the video call:

"For this video visit, I'll have an AI assistant creating notes from our conversation so I can focus on you. The recording is secure and HIPAA-compliant. Is that okay?"

Telehealth-Specific Documentation Requirements

Telehealth visits have specific documentation requirements for billing:

• Document that the visit was conducted via audio/video
• Note the patient's location (state) for licensure
• Specify the technology platform used
• Document that informed consent for telehealth was obtained
• Note any limitations due to the virtual format

Physical Exam Documentation

Virtual physical exams are limited. Document what you can assess:

• General appearance, alertness, distress level
• Visible skin findings
• Range of motion (if patient can demonstrate)
• Patient-reported vital signs (weight, BP if they have a cuff)
• Note limitations: "Physical exam limited by telehealth format"

Workflow Tips

Optimize your telehealth documentation flow:

• Start recording before joining the video call
• Use a second monitor to keep patient information visible
• Verbalize your clinical thinking so it's captured
• End with a clear summary of the plan
• Review the AI note immediately after the visit while context is fresh