A telehealth SOAP note is not a standard SOAP note with the word "telehealth" added to the top. It carries documentation requirements that an in-person note never has to think about, and those requirements are the difference between a visit that gets paid and one that gets denied. Consent, the modality used, where the patient physically was, where the provider was, the place-of-service code, the modifier, none of these appear in a routine office note, yet under the CY 2026 CMS rules, every one of them has to be captured for a telehealth encounter to be complete and billable. Most SOAP note guides skip all of it, which is why so many telehealth notes are clinically fine and administratively incomplete.
This guide covers what a telehealth SOAP note must document under the current CMS rules, section by section, with a worked example and a quick reference for the codes and modifiers that trip people up. It assumes you already know the basic SOAP structure; if you need that foundation first, our guide to SOAP note structure and service covers it. One caution before we start: telehealth policy has been unusually volatile, moving through repeated short-term extensions, so this piece states the status as of August 2026 and flags clearly where it could change.
Quick Answer:
A telehealth SOAP note documents everything a standard SOAP note does, plus the elements CMS requires specifically for remote visits: the patient's consent to a telehealth encounter, the modality used (two-way audio-video, or audio-only where permitted), the patient's physical location at the time of the visit (the originating site), the provider's location (the distant site), the total time, and the participants. On the claim, the visit is coded with the correct place-of-service code, 02 when the patient is not at home, 10 when the patient is at home, and, for synchronous audio-video, appended with modifier 95. As of August 2026, the Consolidated Appropriations Act, 2026 (H.R. 7148, signed February 3, 2026), extended the major Medicare telehealth flexibilities, including home as an originating site with no geographic restriction, through December 31, 2027. Behavioral health telehealth flexibilities are permanent. Because this area changes by Act of Congress, verify current status at Telehealth.HHS.gov before relying on any date.
Why a Telehealth Note Is Different
The clinical content of a telehealth SOAP note follows the same logic as any other: subjective, objective, assessment, plan. What changes is that a remote visit generates a set of administrative facts that an in-person visit takes for granted. When a patient walks into a clinic, their location and the fact of their presence are self-evident. When the same patient is seen over video from their kitchen, none of that is self-evident, and CMS requires it to be written down because location and modality determine whether and how the service is payable.
This is where telehealth notes most often fail, and the failure mode is familiar from ordinary coding. A note that omits consent, or does not state the modality, or never records where the patient was, gives the payer grounds to deny the claim, even when the care was appropriate, the same way an incomplete in-person note drives denials. We covered that denial mechanism in depth in our companion piece on why the wrong note format drives denials, and telehealth simply adds a new layer of elements that have to be present for the note to hold up.
The CY 2026 Rules You Are Documenting Against
Before mapping the note, it helps to know what the current rules actually say, because the note exists to evidence compliance with them. The CY 2026 Medicare Physician Fee Schedule Final Rule (CMS-1832-F), effective January 1, 2026, made several telehealth policies permanent: it removed frequency limitations on subsequent inpatient visits, subsequent nursing facility visits, and critical care consultations, and it permanently adopted a definition of direct supervision that allows the supervising practitioner to be immediately available through real-time audio-video technology (audio-only does not qualify). The originating-site facility fee, billed with HCPCS code Q3014, is set at $31.85 for CY 2026.
Separately from that rule, a set of broader statutory flexibilities, the ones that let a patient be seen at home anywhere in the country rather than only at a rural facility, were scheduled to expire at the end of January 2026. They did not lapse for long: the Consolidated Appropriations Act, 2026, extended them through December 31, 2027, so as of this writing, a Medicare patient may receive telehealth from any location, including home, with no geographic restriction. One forward-looking limit is worth noting now: unless Congress acts again, from January 1, 2028, physical therapists, occupational therapists, speech-language pathologists, and audiologists will no longer be able to bill Medicare for telehealth. Behavioral health telehealth flexibilities sit on firmer ground, having been made permanent, which is why psychiatric and mental health services are the most stable telehealth category. The authoritative, continuously updated source for all of this is the federal telehealth policy portal at Telehealth.HHS.gov, which is where you should confirm any date before you rely on it.
What Each SOAP Section Must Capture
The telehealth-specific elements do not live in one place; they are distributed across the note. Consent and modality usually open the note or sit at the top of the subjective section. The patient's location belongs with the objective documentation, because it is a fact about the encounter. The plan has to account for the limits of a remote assessment, what you could not examine, and what follow-up or in-person evaluation the findings require. The table below maps the standard SOAP sections to the additions a telehealth note needs.
Table 1: What Each SOAP Section Must Add for a Telehealth Visit
SOAP section | Standard content | Telehealth-specific additions |
|---|---|---|
Header/top of note | Patient identifiers, date, encounter type | Patient consent to telehealth; modality (two-way audio-video or audio-only); provider location (distant site) |
Subjective | History of present illness, symptoms, review of systems | Patient-reported home readings (BP, glucose, weight); any barriers to the remote visit |
Objective | Vital signs, physical exam findings, results | Patient physical location (originating site); what was observable on video; explicit note of what could NOT be assessed remotely |
Assessment | Working diagnosis, differential, clinical reasoning | Reasoning built on the available (limited) remote data; note where certainty is constrained by the format |
Plan | Treatment, medications, follow-up, and patient education | Whether an in-person visit or an in-clinic measurement is needed, follow-up modality |
Close | Signature, credentials | Total time, names, and roles of all participants |
The objective section deserves particular attention, because it is the one most distorted by the remote format. In a telehealth visit, you cannot palpate, auscultate, or measure vital signs directly unless the patient has home devices, so the objective section documents what you could observe over video, general appearance, visible skin, respiratory effort, and any patient-reported or device-reported readings, along with an explicit note of what could not be assessed. That honesty matters clinically and medicolegally. The reasoning you then build from that limited objective data is the assessment, and the discipline of separating what you observed from what you concluded is exactly the discipline our guide to the SOAP assessment section lays out, only now with the added constraint that some objective data simply is not available.
Coding the Visit: Place of Service and Modifiers
The documentation and the claim have to agree, and the two fields where telehealth notes most often go wrong are the place of service and the modifier. Place of service tells the payer where the patient was: code 02 for telehealth provided somewhere other than the patient's home, and code 10 for telehealth provided in the patient's home. Choosing between them depends entirely on the patient location you documented in the note, which is why that single fact carries billing weight far beyond its apparent triviality.
The modifier signals how the service was delivered. Modifier 95 identifies a synchronous, real-time telehealth service delivered over audio-video, and it is appended to the service code to show the visit met the interactive requirement. Audio-only encounters, where permitted, use their own designated modifier and require documentation of why video was not used, particularly for behavioral health, where audio-only is permanent but conditional on recording the patient's inability or refusal to use video. The quick reference below summarizes the common combinations.
Table 2: Telehealth Place-of-Service and Modifier Quick Reference
Code / modifier | Use it when | Depends on the note recording |
|---|---|---|
POS 10 | Telehealth provided while the patient is in their own home | Documented patient location = home |
POS 02 | Telehealth provided while the patient is somewhere other than home | Documented patient location = not home |
Modifier 95 | Synchronous, real-time service delivered over two-way audio-video | Documented modality = audio-video |
Audio-only modifier | Audio-only encounter where permitted (behavioral health, or extended non-behavioral) | Documented modality = audio-only + reason video not used |
Q3014 | Originating-site facility fee (billed by the facility where the patient is located) | CY 2026 amount: $31.85 |
Getting these fields right is not a clerical afterthought; a mismatch between the documented location and the place-of-service code is one of the most common reasons a clean clinical note still triggers a denial or an audit query.
Not sure your telehealth notes would survive an audit? |
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The gap between a telehealth note that reads well and one that actually holds up is the administrative layer: consent, modality, patient location, and a place-of-service code that matches them. Send us a note, and a nursing reviewer will check it against the current CMS requirements, section by section, and flag exactly what a payer would question. Have your telehealth notes checked, with an itemized quote back within 2 to 4 business hours, no obligation. |
A Worked Telehealth SOAP Note
Consider a follow-up visit for a stable patient with hypertension, seen over video at home. The note opens by establishing the telehealth facts, then proceeds through the familiar structure. The subjective section records that verbal consent to a telehealth visit was obtained and documented, that the visit was conducted by two-way audio-video, that the patient was at home and the provider at the clinic, followed by the patient's reported history: medication adherence, any symptoms, and home blood pressure readings if available.
The objective section records what the video allowed, general appearance, no acute distress, no visible edema, plus the home blood pressure readings the patient reported, and the fact that a direct cardiovascular examination could not be performed remotely. The assessment states the working clinical judgment, hypertension, controlled or uncontrolled, based on the available readings, with the reasoning. The plan addresses medication continuation or adjustment, the home monitoring the patient will do, and, critically for a telehealth note, whether the limits of the remote assessment require an in-person visit or in-clinic measurement before the next decision. The note closes with the total time and the participants, and the claim carries place-of-service 10 and modifier 95. If you want that structure adapted to your specialty or program template, our nursing documentation support works with students across clinical settings.
Common Telehealth Documentation Mistakes
A handful of omissions account for most denied or returned telehealth notes. The most common is failing to document consent, which many payers require to be recorded for each telehealth encounter or per their stated policy. Close behind is omitting the patient's location, which not only breaks the place-of-service decision but can render the service non-billable if the patient was somewhere telehealth is not covered. Failing to state the modality leaves ambiguity about whether the visit met the interactive audio-video requirement, and mismatching the place-of-service code to the documented location, coding 02 when the note says the patient was home, creates an internal contradiction that invites audit.
The subtler mistake is treating the objective section as if it were an in-person exam, documenting findings that could not have been obtained over video. This is both inaccurate and a compliance risk, because it claims an assessment that did not happen. The correct approach is to document what was actually observable remotely and to state plainly what was not, then let the plan account for the gap. A telehealth note that is honest about its own limits is stronger, not weaker, than one that pretends the remote visit was a full physical examination.
Frequently Asked Questions
What has to be in a telehealth SOAP note that is not in a regular one?
A telehealth SOAP note adds several elements a standard note does not need: documentation that the patient consented to a telehealth visit, the modality used (two-way audio-video or audio-only where permitted), the patient's physical location during the visit (the originating site), the provider's location (the distant site), and the total time. These support the place-of-service code and modifier on the claim. The clinical SOAP structure itself is unchanged; the additions are the administrative facts that make a remote visit payable.
What place-of-service code do I use for telehealth in 2026?
Use place-of-service code 10 when the patient is in their own home during the telehealth visit, and code 02 when the patient receives telehealth at a location other than their home. The choice follows directly from the patient location you document in the note, so recording that location accurately is what makes correct coding possible. For synchronous audio-video services, modifier 95 is typically appended to the service code.
Are Medicare telehealth flexibilities still in effect in 2026?
Yes. The statutory flexibilities that allow a Medicare patient to be seen by telehealth from any location, including home, without a rural geographic restriction, were set to expire in late January 2026 but were extended by the Consolidated Appropriations Act, 2026 (H.R. 7148), signed February 3, 2026, through December 31, 2027. Behavioral health telehealth flexibilities are permanent. Because this area is governed by legislation that has changed repeatedly, confirm the current status at Telehealth.HHS.gov before relying on any specific date.
Can I document a full physical exam in a telehealth note?
No. You should document only what could actually be assessed over the video connection, such as general appearance, visible skin, and respiratory effort, along with any patient-reported or home-device readings, and then explicitly note what could not be examined remotely. Recording exam findings that could not have been obtained during a remote visit is both clinically inaccurate and a compliance risk. The plan should account for anything the remote format prevented you from assessing.
Is audio-only telehealth allowed?
It depends on the service. For behavioral and mental health services, audio-only telehealth is permanently allowed, subject to documenting the patient's inability or refusal to use video. For non-behavioral services, audio-only coverage has been extended along with the other flexibilities through December 31, 2027, but remains conditional and subject to change. When you use audio-only, document the reason and use the designated modifier rather than the audio-video modifier.
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Document the Visit, Not Just the Care
A telehealth SOAP note has two jobs: to record sound clinical reasoning, and to evidence that the remote encounter met the rules that make it billable. The clinical half is the same SOAP discipline you already know. The telehealth half is a short, fixed list: consent, modality, patient location, provider location, time, and the matching place-of-service code and modifier, which have to be present every time. Document those elements as a habit, be honest in the objective section about what a remote visit can and cannot capture, and confirm the current policy dates against the federal telehealth portal rather than from memory, because this is one area of clinical documentation where the rules really do move.
If you are learning to document telehealth encounters for a course or clinical placement and want your notes reviewed against the current CMS requirements, send us the note you are working on. You will receive an itemized quote within 2 to 4 business hours, with no obligation.
