Frequently Asked Questions:
Initial Psychiatric Evaluation
What Telehealth Elements Should Be Added to Psychiatric Evaluation Templates?
To ensure clinical, legal, and billing compliance, psychiatric evaluation templates used for telehealth should include elements specific to virtual care delivery. These additions help document the context of the visit, address technology-related considerations, and meet payer or regulatory requirements.
Key Telehealth Elements to Include:
Key Telehealth Elements to Include:
1. Location of Patient and Provider
Document where both the clinician and client were located during the session (e.g., "Client was located in Maryland; provider was in a HIPAA-compliant private office in Virginia").
2. Mode of Communication
Specify the platform used (e.g., Zoom, Doxy.me, integrated EHR video), and whether the visit was conducted via video or phone.
3. Informed Consent for Telehealth
Include a statement indicating that verbal or written consent for telehealth was obtained and documented.
Example:
“Client provided verbal consent to receive telehealth services and acknowledged understanding of limitations and risks.”
4. Technical or Privacy Issues
Note any disruptions or limitations due to technology, and whether they impacted the assessment.
Example:
“Session experienced minor audio lag; provider confirmed understanding of client responses.”
5. Telehealth-Specific Risk Assessment
Ensure risk assessments account for limitations of remote care, such as the client's physical safety, emergency contacts, and access to crisis resources.
6. Verification of Identity
Some settings require confirming the client’s identity and location, particularly in cross-state or risk-sensitive scenarios.
7. Emergency Protocols
Record that emergency procedures were reviewed, including what to do if the session is interrupted or if there’s a crisis.
Tip:
Consider using annotated telehealth-specific templates that prompt clinicians to address these elements without disrupting clinical flow. ICANotes makes this easy with built-in telehealth documentation features, including a dedicated telehealth informed consent workflow, fields to document patient and provider location, mode of communication, and any technical issues during the session. These structured prompts ensure that all telehealth-specific requirements are captured accurately—helping providers stay compliant with licensing, legal, and billing standards while maintaining efficient workflows.
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