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A telehealth psychotherapy note is the progress note for a therapy session delivered by video or phone. It records everything a standard session note does, plus the telehealth layer: modality, client location, provider location, consent, technology issues, and a session-specific emergency plan. Therapists, psychologists, and counselors write one after every virtual session. A typical telehealth note runs 150 to 400 words.
Therapists, psychologists, counselors, clinical social workers delivering virtual care
Treating clinician, care team, payers, auditors
150 to 400 words · 10 to 20 minutes by hand (clinical team estimate)
Structured progress note with a telehealth layer (compare: SOAP, DAP, BIRP)
After each psychotherapy session delivered by video or phone
No mandated form; state licensure, payer telehealth rules, and consent laws govern the content
A telehealth psychotherapy note is the clinical record of a psychotherapy session delivered by live video or phone. It is not a new document type: it is an ordinary progress note, in whatever format your practice already uses, plus the telehealth facts that matter for licensure, safety, consent, and billing. No standards body ever created a separate telehealth note format. The clinical core descends from ordinary progress-note practice, and the telehealth layer comes from licensure rules, consent statutes, telepsychology standards (the American Psychological Association first adopted telepsychology guidelines in 2013, and the Canadian Psychological Association issued its own in 2023), and payer policy. Clinicians and payers also call it a teletherapy note, virtual therapy note, telepsychology note, telebehavioral health note, or video-visit note.
Two clarifications matter. First, no law or payer mandates a telehealth note format. Medicare's Program Integrity Manual states that progress notes "may be in any form or format." What makes the telehealth layer worth writing is that modality, location, and consent are materially decisive: they determine who may lawfully treat the client, how emergency services would reach them, and how the claim is coded, even though no national rule lists them as required note fields. Second, a telehealth psychotherapy note is not a psychotherapy note in the HIPAA sense. It carries session times, diagnosis, progress, and risk findings, exactly the content HIPAA excludes from that specially protected category, so it belongs in the standard clinical record (see the psychotherapy notes authorization page for the difference).
Any clinician who delivers therapy by video or phone writes one after every virtual session: therapists, psychologists, counselors, and clinical social workers in fully virtual practices, hybrid practices, and integrated care teams. Virtual delivery is now a routine share of care: a 2026 JAMA Psychiatry analysis found that 27.8 percent of US adults in outpatient mental health treatment received all of their care by telehealth, and another 21.5 percent used a mix of virtual and in-person visits. The telehealth layer is format-agnostic: it sits on top of whatever structure you already use, whether SOAP, DAP, BIRP, or a narrative note. When a virtual session becomes an acute crisis encounter, document it as a crisis psychotherapy note instead, with the remote-session facts included.
The note is a standard session note with a telehealth header. Put the telehealth layer where a reviewer looks first: modality (video or audio-only, with the reason if audio-only), the client's location and setting, your location, consent status with its date, and start and stop times. Then document the session with the same clinical substance as an office visit.
Technology and session setup. The platform used, connection quality, any interruptions with times and how they were handled, and who else is present at the client's location. Pitfall: silence about a mid-session drop. If video failed and the session finished by phone, the modality changed, and under Medicare the claim belongs on the audio-only modifier; an unexplained gap also reads as time the record does not support.
Emergency plan for this session. The client's specific location today, confirmed precisely enough for emergency dispatch, a local contact or number, and the reconnect plan if the session drops during a risk discussion. Pitfall: a generic "safety plan on file" line. Ontario's psychology standards expressly require emergency planning tied to services where the client is located, and the operational point everywhere is where the client actually is right now.
Session content and interventions. Presenting concerns, themes, and the therapeutic work delivered, with the same substance as an in-person note. Pitfall: telehealth logistics crowding out the psychotherapy. Medicare's national psychotherapy audit flagged notes with no visible therapeutic work; the billed service is therapy, not a video call.
Mental status and response. What you actually observed on camera or heard by phone: appearance, affect, speech, engagement, and anything the modality limited. Pitfall: charting findings the modality cannot support, such as full appearance and motor detail from a head-and-shoulders frame, or visual observations in an audio-only session.
Assessment, risk and progress. Progress toward treatment plan goals, risk status, and whether telehealth remains clinically appropriate for this client. Pitfall: never revisiting suitability. Ontario requires determining whether virtual care is clinically indicated, and Ahpra tells practitioners to assess and re-assess it; a one-line suitability statement shows that judgment.
Plan and next steps. Interventions for coming sessions, homework, the next appointment, and the planned modality. Pitfall: a bare "continue treatment." Tie the plan to a goal and say whether the next session is video, phone, or in person.
Client: [initials] Date: Session #: Modality: [video / audio-only, reason] Telehealth consent: [on file, date] Client location & setting this session: Provider location: Start/stop times: Technology & session setup (platform, interruptions, others present): Emergency plan for this session (location confirmed, local contact): Session content & interventions: Mental status & response (as observed by video/phone): Assessment, risk & progress (incl. continued suitability for telehealth): Plan & next steps (incl. planned modality): Clinician signature/credentials: Date signed:
Free to use and share, no signup. The PDF includes a one-page cheat sheet with section-by-section pitfalls and a pre-sign checklist; the DOCX is the blank template, ready to adapt.
Scenario: established adult client, major depressive disorder, CBT delivered by video, session 8 of a planned 16. All details are fictional.
Client: D.K., 29 · Date: 07/09/2026 · Session: 8 · Service: Individual psychotherapy by video · Start/stop: 3:02 to 3:55 pm · Psychotherapy time: 51 minutes
Telehealth setup: Video session on the practice's HIPAA-compliant platform. Client at home in Fort Collins, Colorado; address on file confirmed at the start of session. Clinician at the practice office in Denver, Colorado. Telehealth consent on file, dated 03/12/2026. Client alone in a closed room, using headphones.
Technology: Connection stable except one video drop from 3:27 to 3:29 pm. Session resumed by video, the interrupted material was repeated, and the two minutes are excluded from the psychotherapy time above.
Emergency plan: Location confirmed as above. Spouse home and reachable; local emergency contact information on file verified as current. Plan reviewed: if the connection fails during any risk discussion, clinician calls the client back immediately and the client answers by phone.
Session content and interventions: Reviewed behavioral activation homework: activity scheduling completed 5 of 7 days, with morning walks the most consistent entry. Client skipped both planned social activities, citing "not wanting to explain the job search." Cognitive restructuring targeted the guilt-driven avoidance thoughts; client generated an alternative appraisal and rated belief in it 60 percent. PHQ-9 today: 11, down from 14 at session 6.
Mental status and response: Groomed, alert, engaged on camera. Speech normal in rate and tone. Affect mildly dysphoric, brightening when describing the walks. No psychomotor changes visible in frame; full appearance and motor observations limited by the head-and-shoulders video frame. Denied suicidal ideation and self-harm; no risk indicators observed or reported.
Assessment, risk and progress: Steady progress toward Goal 1 (increase engagement in valued activities): activity adherence up and PHQ-9 down three points in two weeks. Symptoms remain consistent with major depressive disorder, moderate, improving. Risk low; routine monitoring continues. Client engages well by video and presentation is stable; telehealth remains clinically appropriate.
Plan and next steps: Continue weekly CBT by video. Homework: maintain the activity schedule and complete one of the two planned social activities before next session. Re-administer PHQ-9 at session 10. Next appointment 07/16/2026, video.
This sample is fictional and for educational purposes. It does not describe a real patient.
Writing these after every session? BastionGPT drafts complete notes from bullets, dictation, or a transcript.
Generate a note from bulletsA telehealth psychotherapy note is part of the designated record set: clients can request it, payers can audit it, and other providers rely on it. Keep private process reflections out of it; those belong in separately maintained psychotherapy notes with their own authorization rules. Medicare review contractors may not request those HIPAA-protected psychotherapy notes, but the Program Integrity Manual makes the flip side explicit: you must supply enough ordinary progress-note documentation to establish the service and its medical necessity, and a claim supported only by content locked inside protected notes can be denied. The telehealth layer itself is mostly not note-field law. No national rule in the US, Canada, or Australia requires a street address, an identity-verification sentence, a "no technology problems" statement, or a repeated consent paragraph in every session note; those facts earn their place because they are materially decisive for licensure, safety, and billing, and because narrower state, provincial, payer, or board rules can make any of them mandatory. Record what is material rather than pasting boilerplate.
For US Medicare, the binding layer is statute and payer policy, and the dates matter right now. The Consolidated Appropriations Act, 2026 extended the major telehealth flexibilities through December 31, 2027 and postponed the behavioral-health in-person visit requirement to January 1, 2028, with clients already in home tele-mental-health care by the end of 2027 grandfathered past the six-month prior-visit rule (CMS telehealth FAQ). Audio-only psychotherapy stays covered for a client at home when you are video-capable but the client "is not capable of, or does not consent to, the use of video technology" (42 CFR 410.78). On claims, the client's site drives the rate: POS 10 (client at home) pays the non-facility rate since January 1, 2024, POS 02 (any other client location) pays the facility rate, and modifier 95 marks video while modifier 93 marks audio-only (CMS Change Request 13582). Medicare's originating site is the client's location and the distant site is yours; templates sometimes reverse them. One caution when checking sources yourself: the displayed eCFR text of 42 CFR 410.78 still shows superseded 2024 dates, and the later 2026 statute controls. The format is a convention; the content, the time, and the claim fields are the requirement.
Location and consent are where state and provincial law bind. Under PSYPACT, the psychologist must be physically in their compact Home State, the client's state is the Receiving State, and the Receiving State's rules govern the work, so both locations are legally consequential even though no rule prescribes a note field for them. On consent, California is a clean example: providers must inform the client and obtain verbal or written consent before delivering care by telehealth, and the statute says the consent "shall be documented" (Business and Professions Code 2290.5). Rules differ by state and board, so check yours. Canada and Australia are summarized in the table below. A telehealth session that becomes an acute crisis gets a crisis note, and a lasting modality change usually also touches the treatment plan.
The national audit record here is unusually direct, because Medicare's biggest psychotherapy audit landed on the telehealth era. During the audit period, 57 percent of Medicare psychotherapy payments went to telehealth services, and the 2023 OIG national audit estimated $580 million in improper payments, $348 million of it for telehealth sessions. Reviewers did not fail notes for missing telehealth boilerplate: the failures were missing time, missing or inadequate treatment plans, missing signatures, and notes with no visible psychotherapy. Medicare's 2024 compliance data for outpatient psychiatric services tells the same story, with insufficient documentation driving 78.3 percent of improper payments. The BastionGPT Clinical Advisory Board sees the same errors most often in telehealth note reviews:
| Aspect | United States | Canada | Australia |
|---|---|---|---|
| Status | No mandated note format; Medicare accepts progress notes "in any form or format"; the telehealth layer comes from statute, payer policy, and state law | No national regime; CPA's 2023 telepsychology guideline is guidance, while provincial college standards bind (Ontario technology and emergency rules, BC's 2026 virtual-care standards) | No separate format; Ahpra holds telehealth to the same standard as face-to-face care, and the Psychology Board's code of conduct governs records |
| Terminology | Telehealth, telemental health, teletherapy note | Virtual care, telepsychology | Telehealth, video and phone attendances |
| What changes | Claim fields: POS 02 or 10 and modifier 95 or 93, plus the December 2027 and January 2028 Medicare dates | Authorization to practise across provinces, Ontario's emergency-plan and identity rules, consent expectations | Separate MBS item numbers for video and phone under Better Access, plus referral and reporting rules |
| Retention | No universal HIPAA or Medicare rule for charts; state law and payer contracts govern | Ontario: 10 years after age 18 or the last contact, whichever is later; BC: 16 years from the last encounter or from the age of majority | Psychologists: 7 years after the last entry, or until the 25th birthday for clients who were minors |
The clinical core travels unchanged across all three countries. What changes is the jurisdictional layer around it: who may treat a client in another state or province, how the modality reaches the claim, and how long the record must survive.
BastionGPT is specifically trained, tuned, and clinically tested on telehealth psychotherapy notes.
See how clinicians use it day to day on the AI therapy notes page.
Many BastionGPT users report saving more than 90 minutes per day on documentation.
HIPAA-compliant with a signed BAA on every plan. Your data is never used to train models. BastionGPT drafts, you review and sign.
Most run 150 to 400 words, about the same as an in-person progress note plus a few header lines for the telehealth layer. Length is not the compliance driver: the failures that cost providers money in Medicare's national psychotherapy audit were missing time, missing plans, and missing signatures, not short notes. Write enough to show the service, the response, and the telehealth facts that matter.
No. No national rule in the US, Canada, or Australia prescribes a telehealth note format. Medicare accepts progress notes "in any form or format," and Canadian and Australian regulators require accurate, complete, contemporaneous records rather than a layout. What is binding sits around the note: licensure tied to location, consent statutes in some states and provinces, and payer claim rules. That is why this page labels each requirement as law, payer policy, or convention.
No universal federal rule says so, but location is the most consequential fact in the telehealth layer. It determines whose licensing rules apply (under PSYPACT, the client's state is the Receiving State), which emergency services can reach the client, and whether the claim is POS 10 (home) or POS 02 (anywhere else). Ontario expressly requires an emergency plan tied to services where the client is located. The defensible habit: record at least the city and state or province every session, and a precise location whenever risk is elevated or the client is somewhere new.
Medicare claim fields, not note fields. POS 10 means the client was at home and has paid the non-facility rate since January 1, 2024; POS 02 means any other client location and pays the facility rate. Modifier 95 marks an audio-video session and modifier 93 audio-only (CMS Change Request 13582). No rule requires repeating them inside the narrative, but the note's modality and location lines are what prove them right in an audit. One orientation check: Medicare's originating site is the client's location and the distant site is yours; templates sometimes reverse the two.
Yes. The broad audio-only flexibility runs through December 31, 2027. After that, a permanent behavioral-health exception still covers phone sessions for a client at home when you are capable of video but the client "is not capable of, or does not consent to, the use of video technology" (42 CFR 410.78). Document the reason for audio-only: that line is what supports modifier 93 and the exception.
Unless Congress acts again, Medicare's in-person requirement for home tele-mental-health takes effect: an in-person visit within six months before the first home telehealth service and roughly annually afterward, with exceptions. Clients who began home tele-mental-health care by December 31, 2027 are treated as established and skip the six-month prior visit (CMS telehealth FAQ). The dates come from the Consolidated Appropriations Act, 2026; the displayed eCFR text still shows older dates, and the statute controls.
Document the interruption with times, what was missed, and how the session resumed, and make the psychotherapy time add up without the gap. If the session finished by phone, the modality changed: under Medicare that is modifier 93 territory, not 95. Australia's MBS handles the same situation with separate video and phone item numbers, so the item must match what actually happened. Commercial payers can differ, so do not generalize Medicare's coding rule to every insurer.
No jurisdiction reviewed for this page requires re-documenting consent in every note. Consent is state and province law: California, for example, requires informed consent before care is delivered by telehealth and requires that the consent be documented. Federal guidance accepts written, electronic, or verbal consent. Obtain it properly once, record where it lives and its date in the note header, and renew it when something material changes: a new platform, recording or AI tools, new participants, or cross-border care.
Yes. Give it a few bullets, a dictation, or a transcript, and it drafts the full note with the telehealth layer in the right places: modality, locations, consent status, technology events, and the emergency plan, plus the clinical content. BastionGPT is HIPAA-compliant with a signed BAA on every plan, and your data is never used to train models.
The compliance claims on this page trace to these authorities, last verified July 2026:
Educational content, not legal or billing advice. Sample notes are fictional. Follow your organization's policies and your board, payer, and jurisdiction requirements.