Telemental Health Documentation: 5 Things to Write Down

Documentation is everyone’s favorite part of therapy!* So it’s a good thing that when we provide services via telemental health, there are a few extra items to write down. We’ve even provided a sample form you can use to add to your own documentation templates. (*This statement is false)

Before jumping into the details, I should note that one article is not enough space to fully explore the issues that arise in a telemental health session (and therefore need to be documented.) We all need to be competent in the services we offer, including competence to perform them via telemental health media (e.g. videoconferencing.) If you need training to get there, we have a telemental health certificate program here, and there are similar programs offered by other companies, as well.

Telemental Health Documentation: What are the Special Elements?

When working remotely with a client who is meeting you from their own space (e.g. home office, laundry room, car, etc.), there are several things that need to be checked on which you normally would have control over in your own office.

Imagine scheduling an appointment with a new client, but you have to meet them in a randomly chosen room in a randomly chosen building. Also, the client can go there to help prep it before you arrive, but you can’t go there until it’s time for the session to start.

• How do you ensure that it’s a private space?
• How do you make sure random (or not-so-random) people aren’t there or don’t walk in during session?
• How do make sure the space is therapy-affirming?

This mental exercise doesn’t cover the entire picture of telemental health delivery to a client’s space, but it covers quite a bit. And some of the special considerations that need to be made in an online session should be documented. Let’s take a look at the most common ones.

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Telemental Health Documentation Common Items List

1) The client’s location. Get the address if it’s available. Confirming the location lets you know what jurisdiction (i.e. state or country) the client is in at the time of session. You also need to know where they are if you need to send emergency help, such as an ambulance. Insurance companies also like it when you document this item.

A lot of online therapy clients do all their sessions in the same room. If you already know the address, simply document that they are at that same address.

2) Confirmation of client identity (and possibly age.) This can mean a couple of different things. While only some therapists ask for clients to show identification at the first in-person session, many telemental health standards would have you do either that or something equivalent to it any time you perform an intake online. This lets you confirm that the client is who they claim to be and also lets you confirm their age (e.g. that they are or are not a minor.)

At each encounter, you also need to make sure that you’re communicating with your actual client and not someone who is pretending to be them. With the audio-visual connection provided by videoconferencing, this usually isn’t a problem. But it can be difficult in other situations. If you can’t verify the client’s identity by seeing their face and/or hearing their voice, you can instead use codewords that you and the client decided on at the first session.

3) Confirmation that the scene is safe. Online therapists have a few strategies for ensuring that the client’s space is safe and appropriate — safe from hiding abusers/intruders, likely to be good for privacy, etc. Whatever technique(s) you use, you should document that you used them. Also document your conclusion regarding whether or not it appeared safe to proceed.

4) Safety and emergency planning. Part of intake with new telemental health clients is making a plan with them for dealing with technology failures, mental health crises, or other relevant emergencies. If you update this plan, or just revisit it with the client, make sure to document that you did so (in addition to documenting any new elements of the plan, of course. Our telemental health certificate course includes a planning template, if you need one.)

5) Assessment of appropriateness for telemental health. An important — and consistent — element of different telemental health standards is the need to assess if telemental health is appropriate for the client and the work you’re doing with them. Explaining how this works and what to look for requires a lot more than can be fit in a single listicle bullet, so I’ll leave that topic for another time. Suffice to say, however, that you should document what assessments you do and document your conclusions, as well.

If you want some help with that, we have a Sample Telemental Health Session Documentation Form document available for our free newsletter subscribers. It takes the elements of the above list and puts them into handy checkboxes you can add right into your session documentation template. Enjoy!

Sign up free and get the Sample Telemental Health Session Documentation Form→