How to Write SOAP Notes for Telehealth Visits

A telehealth visit can be over in fifteen minutes, but the note still has to support clinical decisions, continuity of care, and billing. CMS states that timely payment for telehealth depends on complete and accurate documentation and coding, the same standard that applies to in-person care.

Virtual encounters also need details that in-person notes usually leave out: consent, modality, where the patient and clinician were, and what the remote exam could not assess. A telehealth SOAP note is a standard Subjective, Objective, Assessment, Plan note adapted to a remote encounter, with those additions built in. This guide walks through the prerequisites, each SOAP section, a worked example, and common pitfalls. The clinician reviews and approves every note.

Prepare Before the Visit

Telehealth Documentation Prerequisites

Start with consent and identity. HHS guidance on telehealth informed consent says consent can be documented in writing, electronically, or verbally at the start of the session. The same guidance calls for confirming the patient's identity before you discuss protected health information.

Next, record locations and modality. The patient's location matters for licensure, since you generally need to be licensed in the state where the patient is physically located. It also matters for billing. Medicare's telehealth payment policies separate audio-video from audio-only communication and look at the patient's site. Place of service carries the same detail. In the CMS place of service codes, POS 02 means telehealth provided somewhere other than the patient's home, and POS 10 means telehealth in the patient's home.

Finally, note the platform, any technical problems, and who else was present. HHS advises providers to conduct telehealth in private settings. If a family member or interpreter joins, name them in the note.

• Consent: Verbal, written, or electronic, with date and time. Why it matters: Compliance and state requirements.
• Identity: How you verified it. Why it matters: Privacy of PHI.
• Locations: Patient and clinician, including state. Why it matters: Licensure, POS coding.
• Modality: Audio-video or audio-only. Why it matters: Billing eligibility.
• Participants: Names and roles. Why it matters: Privacy and consent.
• Technical issues: Lag, dropped video, poor lighting. Why it matters: Explains limits of the exam.

Templates, Tools, and EHR Fit

A reusable telehealth template means you won't have to remember these fields from scratch every visit. Most major EHRs offer text macros and structured note builders. Many documentation tools also support custom SOAP templates with fields for virtual exam findings, such as "observed on video" and "patient-assisted maneuver."

Ambient SOAP note apps capture the conversation, often through medical speech-to-text, and produce a structured draft for the clinician to review. When you evaluate one, check for:

• HIPAA compliance and a signed business associate agreement (BAA)
• EHR integration, for example through the SMART on FHIR standard, which supports launching and authorizing apps inside the EHR
• Templates that teams can share across sites and specialties
• A required review step before any note is signed

Write the SOAP Note

SOAP Step by Step

Subjective. Record the chief complaint, HPI, ROS, medications, and allergies. Use the patient's own words where they add clinical meaning. In a remote visit most of the history is self-reported, so make that clear.

Objective. Include vitals the patient reported or measured on a home device, findings you saw on video, and maneuvers the patient performed at your direction. Label each item observed or reported. "Home BP 128/82 per patient's cuff" is accurate. "BP 128/82" alone suggests you took it yourself.

Assessment. Give the differential and your reasoning. Say how confident you are and which limits of the remote exam affected your conclusion.

Plan. List orders, e-prescriptions, patient education, follow-up timing, and safety-net instructions. Spell out the criteria for converting to an in-person visit. Clear escalation criteria make up for the narrower exam.

Worked Example and Pitfalls

Here is an abbreviated note for an audio-video visit for suspected UTI:

• Subjective: 34-year-old with 2 days of dysuria, frequency, and urgency. Denies fever, flank pain, or vaginal discharge. No drug allergies.
• Objective: Appears comfortable on video and speaks in full sentences. Home temperature 98.4°F, patient-reported. CVA tenderness not assessable remotely.
• Assessment: Probable uncomplicated cystitis. Pyelonephritis is less likely given no fever or flank pain, but the remote exam limits how confidently it can be excluded.
• Plan: Urinalysis and culture ordered. Antibiotic e-prescribed. Hydration advice given. Return or seek in-person care for fever, flank pain, vomiting, or no improvement in 48 to 72 hours.
• Attestation: Clinician reviewed, edited, and signed.

Four mistakes come up often:

1. Copy-forward of in-person exam text. Carried-over lines like "abdomen soft, nontender" claim findings you never examined.
2. Missing consent, location, or modality. Any one of these gaps leaves the record incomplete for compliance and billing.
3. Vague "virtual exam normal" entries. State what you observed and what you could not assess.
4. Signing AI-drafted notes without line-by-line review. Drafts can contain misheard medications or details nobody said. The CMS telehealth toolkit is clear that the documentation must be accurate, and the signing clinician owns it.

Bringing It Together

An accurate telehealth SOAP note comes down to three habits: capture the prerequisites before the visit, use a structured template, and document the limits of the remote exam plainly. An ambient tool such as Skriber can draft the note and cut documentation time. The clinician still edits, approves, and signs the final record.

Frequently Asked Questions

What must a telehealth SOAP note include?

It needs the standard SOAP elements plus consent, modality, the patient's and clinician's locations, any other participants, and any technical limitations that affected the exam.

What are ambient SOAP note apps?

They are AI tools that listen to the clinical encounter, usually with medical speech-to-text, and draft a SOAP note. The clinician edits and approves the draft before it goes into the EHR.

Which documentation tools offer custom SOAP templates?

Major EHRs support custom templates through their built-in note builders and text macros, and many ambient documentation platforms do too. Organizations with several teams should look for specialty-specific templates that can be shared across teams.