Telehealth SOAP Notes: Complete Documentation Guide for 2026

Updated January 2026

Telehealth has become an integral part of healthcare delivery, with virtual visits now accounting for a significant portion of patient encounters across all specialties. Proper documentation for telehealth visits requires understanding both traditional SOAP note principles and the unique regulatory requirements that apply to virtual care.

This guide covers everything you need to know about documenting telehealth encounters in 2026, including the latest CMS regulations, HIPAA compliance requirements, and best practices for audio-visual and audio-only visits.

2026 Regulatory Landscape

Key CMS Changes Effective 2026

The CY 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F) introduces several important changes for telehealth documentation:

1. Streamlined Telehealth Services List: CMS has simplified the process for adding services, removing the distinction between provisional and permanent telehealth services.

2. Direct Supervision Definition: The definition now permanently allows supervision through real-time audio-visual interactive telecommunications (excluding audio-only).

3. Frequency Limitations Removed: Permanent removal of frequency limitations for subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations.

Mental Health Telehealth Requirements

Per Section 1834(m) of the Social Security Act, effective after January 30, 2026:

• In-Person Requirement: An in-person, non-telehealth visit is required within 6 months prior to the first mental health telehealth service
• Established Patients: Patients who began receiving mental health services on or before January 30, 2026, are considered established and require at least one in-person visit every 12 months
• Documentation: Must document the date of the qualifying in-person visit

Audio-Only Services (Through January 30, 2026)

According to CMS Telehealth FAQ CY 2026:

• Beneficiaries may receive audio-only telehealth services in their homes through January 30, 2026
• Starting January 31, 2026, audio-only is permitted for behavioral health services only, provided:
  • The practitioner is technically capable of using audio-video technology
  • The beneficiary is not capable of, or does not consent to, using audio-video technology
• Must document the reason audio-only was used

Required Documentation Elements for Telehealth

Pre-Visit Documentation

Every telehealth encounter must document:

1. Patient Identity Verification

   • Method used to confirm patient identity
   • Example: "Patient identity verified via visual confirmation and DOB verification"

2. Patient Location

   • State where patient is physically located (critical for licensure)
   • Specific setting if relevant (home, workplace, etc.)
   • Example: "Patient located at home in California"

3. Provider Location

   • State where provider is located
   • Example: "Provider conducting visit from clinic in Texas"

4. Technology Platform

   • Platform used for the encounter
   • Example: "Visit conducted via Zoom for Healthcare (HIPAA-compliant)"

5. Consent for Telehealth

   • Documentation that patient consented to telehealth services
   • Per HHS Telehealth Policy, verbal consent is acceptable but must be documented
   • Example: "Patient verbally consented to receive care via telehealth. Consent documented."

Technology and Connection Quality

Document any technical issues that may impact care:

• Audio/video quality assessment
• Any interruptions or disconnections
• Impact on ability to assess patient
• Example: "Good audio/video quality throughout. Brief 30-second disconnection at minute 15, reconnected without issue."

Subjective Section (S) for Telehealth

The Subjective section in telehealth visits follows standard SOAP principles with additional telehealth-specific elements.

Subjective Section Components

1. Chief Complaint

   • Primary reason for the telehealth visit
   • Example: "Follow-up for hypertension management via scheduled telehealth visit"

2. History of Present Illness

   • Detailed description using standard HPI elements
   • Note any symptoms that would typically require in-person evaluation
   • Example: "Patient reports blood pressure readings at home averaging 135/85 over the past week"

3. Patient-Reported Outcomes

   • Self-monitored data (BP, glucose, weight, etc.)
   • Symptom tracking app data if available
   • Example: "Patient sharing screen showing BP log from home monitoring device"

4. Remote Monitoring Data

   • Data from connected devices (if applicable)
   • Per CMS Remote Patient Monitoring guidance
   • Example: "RPM data reviewed: Average BP 138/86 over 30 days, 95% transmission compliance"

5. Functional Status

   • Impact on daily activities
   • Work/school/social functioning
   • Example: "Patient reports being able to perform all ADLs without limitation"

6. Environment Assessment (when visible/relevant)

   • Home safety observations if on video
   • Social determinants of health observations
   • Example: "Patient appears in clean, well-lit home environment"

Example Subjective Section for Telehealth

Objective Section (O) for Telehealth

The Objective section requires adaptation for the virtual environment, acknowledging limitations while maximizing observable data.

Objective Section Components

1. Vital Signs (When Available)

   • Patient-reported or remote monitoring device data
   • Document source of vital signs
   • Example: "BP 134/82 (patient-reported from home cuff, Omron brand)"

2. General Appearance (Video Assessment)

   • Overall appearance, alertness, distress level
   • Grooming, hygiene (if relevant to condition)
   • Example: "Patient appears well-groomed, alert, in no acute distress. Appropriate affect."

3. Visible Physical Examination

   • Document what can be assessed via video
   • Skin lesions (patient-directed camera)
   • Range of motion (patient demonstration)
   • Gait assessment (if patient can show)
   • Example: "Patient demonstrated full ROM of right shoulder without visible grimacing"

4. Virtual Physical Exam Techniques

   • Patient self-palpation with guidance
   • Observation of patient-performed tests
   • Example: "Patient performed self-palpation of abdomen as directed; reported no tenderness"

5. Review of External Records/Data

   • Lab results, imaging reports
   • Data from connected devices
   • Records from other providers
   • Example: "Reviewed lab results from Quest dated 12/15/2025: HbA1c 7.2%"

6. Limitations Documentation

   • Explicitly state what could not be assessed
   • Clinical reasoning for proceeding despite limitations
   • Example: "Limited physical exam via telehealth; unable to perform fundoscopic exam. Patient asymptomatic and will have in-person annual exam in 2 months."

Tips for Telehealth Objective Documentation

• Always document the source of vital signs (patient-reported, home device, RPM)
• Note video quality if it impacted assessment
• Be explicit about what could and could not be examined
• Document any patient-demonstrated maneuvers or self-examination
• Include rationale for why telehealth was appropriate despite exam limitations

Example Objective Section for Telehealth

Assessment Section (A) for Telehealth

The Assessment synthesizes telehealth findings with acknowledgment of virtual care context.

Assessment Section Components

1. Clinical Diagnosis/Impression

   • Primary and secondary diagnoses
   • ICD-10 codes as applicable

2. Telehealth Appropriateness Statement

   • Brief statement on why telehealth was appropriate for this visit
   • Document if in-person follow-up needed

3. Response to Treatment

   • Progress toward goals
   • Medication efficacy/tolerability

4. Risk Stratification

   • Assessment of stability
   • Need for escalation to in-person care

Example Assessment Section for Telehealth

Plan Section (P) for Telehealth

The Plan section includes standard treatment planning plus telehealth-specific elements.

Plan Section Components

1. Medications

   • New prescriptions, changes, or continuations
   • E-prescribing documentation
   • Example: "Metformin continued. E-prescription sent to CVS Pharmacy"

2. Patient Education

   • Education provided during telehealth visit
   • Resources shared electronically
   • Example: "Discussed importance of annual dilated eye exam. Emailed ADA diabetes management resources."

3. Follow-Up Plan

   • Next telehealth vs. in-person visit
   • Criteria for seeking in-person care sooner
   • Example: "Follow-up telehealth in 3 months. In-person comprehensive exam scheduled for February."

4. Care Coordination

   • Referrals placed
   • Communication with other providers
   • Example: "Referred to ophthalmology for annual diabetic eye exam; referral sent electronically"

5. Remote Monitoring Instructions (if applicable)

   • Continued home monitoring expectations
   • RPM device instructions
   • Example: "Continue daily fasting glucose checks and BP monitoring. Results will be reviewed via patient portal."

6. Safety Net Instructions

   • Clear instructions for when to seek in-person/emergency care
   • Example: "Return to clinic or ED for: glucose above 300 or below 70 with symptoms, chest pain, severe headache, or signs of infection in feet"

Example Plan Section for Telehealth

Audio-Only Visit Documentation

For visits conducted via telephone only (through January 30, 2026 for non-behavioral health; ongoing for behavioral health after that date with restrictions):

Required Documentation for Audio-Only

Per CMS regulations:

1. Reason for Audio-Only: Document why audio-video was not used

   • Patient preference
   • Technology barriers
   • Patient not capable of video technology

2. Technical Capability Statement (required after January 31, 2026 for behavioral health):

   • Provider attestation of capability to use audio-video
   • Patient's stated reason for audio-only

Example Audio-Only Documentation

HIPAA Compliance for Telehealth Documentation

Per HHS HIPAA Telehealth Guidance:

Documentation Requirements

1. Platform Compliance: Document use of HIPAA-compliant platform
2. Patient Privacy: Note if patient confirmed private location
3. Others Present: Document anyone else present during visit (either side)
4. Recording Consent: If session recorded, document consent

Example HIPAA Compliance Statement

Special Populations: Mental Health Telehealth

42 CFR Part 2 Compliance (Substance Use Disorder)

Per the 42 CFR Part 2 Final Rule (compliance deadline: February 16, 2026):

• Substance use disorder records require additional consent documentation
• Single consent now permitted for treatment, payment, and healthcare operations
• Document specific consent for telehealth SUD services
• New protections for SUD counseling notes (similar to psychotherapy notes)

In-Person Visit Documentation

For mental health telehealth after January 30, 2026, document:

• Date of last in-person visit (must be within 6 months for new patients)
• For established patients: Date of most recent annual in-person visit
• Medical necessity for continued telehealth if in-person not feasible

Free Telehealth SOAP Note Template

Official Resources and References

CMS (Centers for Medicare & Medicaid Services)

• CY 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F)
• Telehealth FAQ Calendar Year 2026 (Updated 11/26/2025)
• List of Telehealth Services CY 2026
• Telehealth & Remote Patient Monitoring Guide (MLN901705)

HHS (Department of Health and Human Services)

• HIPAA and Telehealth
• HIPAA Rules for Telehealth Technology
• Audio-Only Telehealth HIPAA Guidance
• 42 CFR Part 2 Final Rule Fact Sheet

Federal Register

• 42 CFR Part 2 - Confidentiality of Substance Use Disorder Patient Records

Related Guides

• Step-by-Step SOAP Note Guide - Foundational SOAP note writing
• Psychiatry SOAP Notes - Mental health documentation
• Psychotherapy SOAP Notes - Therapy session documentation
• Nurse Practitioner SOAP Notes - Primary care documentation