How to Modernize EHR Documentation for Telehealth Visits in 2025

The origins of telehealth are no longer pandemic-related. What started off as a COVID-19 crisis-driven remedy is now a fundamental component of contemporary healthcare delivery. According to surveys, the majority of doctors still use telehealth to provide some of their patient care, even if in-person visits have returned in several specialties.

Convenience is not the only effect. In underprivileged and rural areas, where clinicians are still in short supply, telehealth is helping to close access gaps. By 2025, the worldwide telehealth market is expected to reach a value of over USD 55 billion. Advanced systems that integrate AI, remote monitoring tools, and adaptable hybrid care models are driving this expansion.

But there are still difficulties. One persistent issue with EHR systems is documentation. Clinicians frequently switch between patient records and audiovisual platforms. Duplicate data entry, disjointed workflows, and persistent worries about HIPAA-compliant telemedicine documentation continue to plague many. The urgency is only increased by burnout. Ineffective documentation is one of the main causes of the high stress levels reported by nearly 44% of clinicians. 

Simplified EHR workflows are not just useful in today’s setting. They are essential for providing high-quality service, maintaining compliance, and guaranteeing prompt payment.

In 2025, this revised guidance closely examines how providers might enhance telehealth documentation. It makes use of recent studies, useful advice, and emerging technological trends. Assisting practices in developing smooth EHR workflows that facilitate safe, effective telehealth sessions while upholding patient pleasure and trust is the aim.

Why Robust Telehealth Documentation Matters

The foundation of safe, dependable treatment is documentation. It offers medico-legal protection, promotes compensation, and safeguards patients. The expectations remain the same in virtual care. The same level of care that clinicians would provide during an in-person visit must be displayed.

Precise telehealth documentation is essential:

• Billing and regulatory compliance: Medical necessity, visit length, and services rendered must all be documented in patient records. Providers run the risk of payer audits or denials without this information.
• Continuity of care: Other doctors can obtain a full history when telehealth notes are integrated straight into the EHR. This lessens the possibility of pharmaceutical errors and duplicate testing.
• Risk management: Comprehensive documentation aids in the defense against allegations of misconduct. Noting the locations of both patients and providers is crucial for telehealth to handle jurisdiction and licensing.
• Patient confidentiality and trust: Strong business associate agreements and safe telehealth platforms are necessary for HIPAA-compliant paperwork. These precautions protect patient health data.

While maintaining provider workflow efficiency, telehealth delivers safe, compliant, and trustworthy care thanks to clear, structured documentation.

Challenges in Telehealth Documentation

Despite its benefits, telehealth introduces unique documentation hurdles:

• Cognitive burden and burnout. Clinicians often switch between video feeds and EHR screens, creating “double entry” and cognitive overload. This contributes to burnout, which affects nearly half of physicians.
• Complex workflows. In the absence of integration, physicians have to re-enter notes into the EHR and the telehealth platform, which lengthens visit times and increases the possibility of mistakes.
• Fragmented data. Patients’ and care teams’ easy access may be hampered by the incompatibility of distinct telehealth technologies with current patient portals.
• Compliance confusion. Many firms are unsure of what constitutes HIPAA-compliant telemedicine documentation due to the rapid policy changes that occurred during and after the epidemic.

Integrate Telehealth and EHR for a Unified Workflow

Integrating telehealth appointments directly into your EHR is the largest step toward more straightforward documentation.

As highlighted by health‑IT experts, combining virtual visit functionality with the EHR eliminates toggling between platforms and automates patient data entry. Key benefits include:

• Floating video window: These days, floating video screens are supported by telehealth platforms. Real-time note-taking allows clinicians to stay in close eye contact with their patients. This improves the relationship between the patient and the clinician and lessens distractions.
• One source of truth: The patient’s chart receives the documentation that was taken during the virtual visit. By doing this, redundant data entry is removed, and records are maintained uniformly throughout the care team.
• Simplified scheduling: Follow-up is made easy by integrated patient portals. Without ever leaving the telehealth site, patients can message the front desk, make an appointment for their next visit, or ask questions.
• Patient-centered care: Healthcare professionals have instant access to patient history, preferences, and health information. Clinicians can work together to make decisions and customize care in real time when this context is provided during the visit.

Use a Second Screen to Maintain Connection

Many clinicians still rely on separate telehealth and EHR programs. When integration isn’t possible, using a second screen, a laptop, tablet, or monitor can ease the burden. 

Keep your camera and EHR on the main screen and display the patient’s video feed on the secondary screen. This configuration allows providers to document while maintaining visual connection, reducing the risk of missing non‑verbal cues.

Best‑Practice Checklists for Telehealth Documentation

A 2022 analysis of telehealth record practices identified essential data elements for quality documentation. Combined with practical guidance from risk‑management experts, the following checklist can be incorporated into your EHR templates:

1. Visit the modality and technology. Specify whether the encounter was conducted via a secure audio‑video platform, telephone, or asynchronous message. Include the software name to demonstrate the use of a HIPAA‑compliant platform.
2. Participant identities and locations. Document the patient’s physical location (e.g., “at home in Tennessee”) and the clinician’s location (clinic, home office) for licensure and billing purposes. Record all participants on both ends—family members, caregivers, interpreters, or chaperones.
3. Informed consent. Summarize the discussion of risks, benefits, and alternatives to telehealth and include the signed consent form.
4. Length of encounter. Capture start and end times to substantiate billing.
5. Visit appropriateness and patient environment. Assess whether telehealth is suitable for the patient’s condition; document environmental distractions, safety concerns, and whether any physical exam components were patient‑assisted.
6. Limitations and technical issues. Note any video or audio problems, incomplete examinations, or blurred images to explain potential limitations in care.
7. Telehealth‑specific templates and training. Use EHR templates with checkboxes or dropdowns for these elements. To guarantee uniformity, train employees and provide practice-specific guidelines and checklists.

Embrace AI and Voice Technologies for Effortless Documentation

Clinical documentation is transforming thanks to artificial intelligence and natural language processing. AI‑enabled ambient scribes capture spoken conversations during telehealth visits and convert them into structured notes. 

A March 2025 report from the Peterson Health Technology Institute found that these ambient scribes are “one of the fastest technology adoptions in healthcare history,” with about 60 solutions in implementation. They lessen the workload associated with paperwork and free up professionals to concentrate on patients rather than typing.

AI can enhance clinical choices by analyzing big databases in addition to transcribing. EHR companies are implementing AI-powered voice recognition and virtual scribes to alleviate the load of documentation, according to industry analysts.

Personalized treatment plans are made possible by sophisticated algorithms that can understand speech, anticipate patient demands, and allocate resources as efficiently as possible. Together, these tools:

• Automate note creation. Capturing real‑time dialogue reduces after‑hours charting and eliminates duplicate entry.
• Enhance data accuracy. Natural language processing converts colloquial speech into standardized medical codes.
• Provide decision support. Machine learning models analyze historical data to highlight potential diagnoses or care gaps.
• Improve reimbursement. Ambient scribes are expanding into coding and revenue‑cycle workflows, helping organizations optimize evaluation and management codes.

However, the report cautions that evidence for time savings is still emerging. Pilot programs should evaluate clinician satisfaction, note quality, and financial impact before full deployment.

Related: The Ultimate Guide to AI in Telehealth: Chatbots, Diagnostics Tools & Beyond

Remote Monitoring, Wearables, and Hybrid Care

Telehealth is no longer limited to video calls. Devices for remote patient monitoring have become essential to virtual care. Continuous streams of data are sent directly to clinicians by devices like as glucose sensors, blood pressure cuffs, and smartwatches. The adoption rate has remained high even after the pandemic. Healthcare executives note that remote monitoring is assisting providers in reducing readmissions and enhancing the treatment of chronic diseases.

Additionally, wearable technology is developing. In order to provide real-time notifications and allow for individualized coaching during or in between visits, new technologies are increasingly connecting with telehealth systems. This change transforms routine monitoring into a model of proactive care.

Meanwhile, hybrid care is becoming more popular. These methods establish a more balanced approach by combining virtual and in-person encounters. Experts anticipate more sophisticated hybrid care by 2025. While difficult cases still require in-person care, routine follow-ups will frequently take place via telehealth. Patients benefit from increased flexibility, increased satisfaction, and more effective use of clinic resources as a result.

Ensure HIPAA‑Compliant Telehealth Documentation

Privacy and security are still of utmost importance. The HIPAA Rules must be followed by all telehealth services, the U.S. Department of Health and Human Services reminds providers. Physicians ought to:

• Use certified telehealth platforms. Select suppliers who use encryption and sign a Business Associate Agreement.
• Document technology details. Determine the software being used and its level of compliance.
• Inform patients. As mandated by HHS guidelines, describe privacy threats and security measures.

Since emergency waivers for the use of consumer platforms such as FaceTime ended in 2023, mainstream services are now required to comply with HIPAA regulations.

For instance, the Consolidated Appropriations Act of 2024 extended telehealth allowances for Rural Health Clinics and Federally Qualified Health Centers through the end of 2024. Telehealth providers should keep an eye on changes to federal and state policies.

Related: A Step-by-Step Guide to Launching a HIPAA-Compliant Telehealth Service

Vozo All-In-One Cloud EHR for Healthcare Practices

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The Vozo Customized EHR solution benefits your healthcare practice by:

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Our specialty-specific tools, such as scheduling, patient portals, lab integration, cloud hosting, and more, meet the specific needs and requirements of your healthcare practice.

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