HIM 350 Module 2 Telehealth Short Paper Example

When the Session Is on a Screen: Telehealth Evidence and Documentation at Sandstone Behavioral Health

[Student Name]

Southern New Hampshire University

HIM 350: Communication and Technologies

Module Two Short Paper

[Instructor Name]

[Date]

The organization, setting and figures below are a composite written as a model document. No real employer, client, colleague or patient is described.

When the Session Is on a Screen: Telehealth Evidence and Documentation at Sandstone Behavioral Health

Telehealth has become ordinary at Sandstone Behavioral Health, where nearly half of therapy sessions now take place by video or phone. Ordinary does not mean simple. Each remote visit raises questions about whether it works as well as an office visit, whether the client has privacy and what the record must show for the visit to be billed and defended. This paper addresses those questions and reports what an audit of Sandstone's telehealth notes found.

Four Modalities

Telehealth covers several different ways of delivering care at a distance. Synchronous video visits connect client and clinician in real time with sound and picture. Audio-only visits use the telephone and matter most for clients without broadband or devices. Asynchronous, or store-and-forward, care sends information such as a questionnaire or image for later review. Remote patient monitoring transmits data such as blood pressure or medication adherence from home devices. Sandstone uses the first two for therapy and psychiatry and asynchronous screening questionnaires before intake.

Does Telemental Health Work?

The research is encouraging. Hilty et al. (2013) reviewed a decade of studies and concluded that telemental health was effective for diagnosis and assessment across adults, children, older adults and diverse ethnic groups, in settings from emergency departments to homes, and appeared comparable to in-person care, while increasing access. Shigekawa et al. (2018), reviewing telehealth evidence across fields, found mental health among the areas with the strongest support. These findings justify Sandstone's continued use of video for therapy and medication management.

National Use Patterns

Patel et al. (2021) showed that during the pandemic, telemedicine use varied widely by specialty, and psychiatry stood out as the field most dependent on remote visits. Behavioral health's reliance on conversation rather than physical examination explains much of that difference. For agencies like Sandstone, telehealth is not a temporary substitute but a lasting part of how services are delivered.

Where Telehealth Falls Short

Remote care is not right for every client or every visit. Clients experiencing a crisis, those without a private place to talk and those whose symptoms are hard to assess on screen may need in-person care. Audio-only visits lose visual cues, such as signs of self-harm or intoxication. Sandstone's no-show rate is 14% for video visits and 11% for in-person visits, and higher still among clients on Medicaid, suggesting that technology barriers affect some groups more than others.

What a Telehealth Note Must Show

A telehealth note needs everything an office note needs plus several elements specific to remote care. Table 1 lists the elements Sandstone's HIM department requires. The client's physical location matters because licensure, emergency response and some payment rules depend on where the client is. Consent to telehealth should be documented at least once and renewed according to policy. Technical problems that shortened or changed a session must be recorded, since they affect billing and continuity.

Table 1. Required Telehealth Documentation Elements

Note. Sandstone HIM documentation standard, current version.

What the Audit Found

The HIM department reviewed 200 randomly selected telehealth notes from the past quarter. Client location was missing or vague, such as "home" without a city or state, in 23% of notes. Documentation of telehealth consent could not be found for 9% of clients. Modality was clear in almost every note, but 14% of audio-only sessions were recorded with the video template, which would lead to incorrect billing. Only 3% of notes mentioned technical problems, though clinicians report that dropped connections are common.

Table 2. Telehealth Documentation Audit Results (200 Notes)

Note. Audit by the HIM department; random sample of notes from the most recent quarter.

Privacy on Both Ends

Telehealth moves part of the session into spaces the agency does not control. Clinicians working from home must use a private room, a headset and the agency's approved video platform, which operates under a business associate agreement. Clients, however, may be in a car, a shared apartment or a workplace break room. Sandstone's clinicians now begin each remote session by asking whether the client can speak privately and agreeing on a code word the client can use if someone walks in. The answer, and any decision to reschedule, belongs in the note.

Coding Basics

Telehealth claims usually carry the same service codes as in-person visits, with a place-of-service code and modifier that identify the remote setting. For Medicare, place-of-service 10 identifies telehealth provided in the patient's home, modifier 95 identifies synchronous audio-video services for certain payers and modifier 93 identifies audio-only services. Payer rules differ, so Sandstone's billing team maintains a payer grid that coders and clinicians can check.

Rules That Keep Changing

Telehealth policy has shifted repeatedly since 2020. Medicare coverage of many services from home has depended on temporary extensions, though behavioral health has permanent status subject to requirements Congress has repeatedly postponed. Clinicians may practice only where they are licensed for the client's location, although interstate compacts for psychologists and counselors help. Federal rules for prescribing controlled medications by telemedicine, including buprenorphine for opioid use disorder, have changed several times. Sandstone's compliance officer issues a quarterly update so staff work from current rules.

Recommendations

Four changes would strengthen Sandstone's telehealth documentation. Add a required structured field for client location with city and state. Build a consent reminder that appears when consent is missing or expired. Make modality a required first choice that selects the correct template automatically. And add a quick checkbox for technical problems with a short free-text field. The HIM department will repeat the audit in six months.

Conclusion

Research supports telemental health as effective and comparable to in-person care, and Sandstone's clients depend on it. The audit shows the record has not caught up: location, consent and modality are too often missing or wrong. Structured fields and reminders can close those gaps and protect both clients and the agency.

References

Hilty, D. M., Ferrer, D. C., Parish, M. B., Johnston, B., Callahan, E. J., & Yellowlees, P. M. (2013). The effectiveness of telemental health: A 2013 review. Telemedicine and e-Health, 19(6), 444-454. https://doi.org/10.1089/tmj.2013.0075

Patel, S. Y., Mehrotra, A., Huskamp, H. A., Uscher-Pines, L., Ganguli, I., & Barnett, M. L. (2021). Variation in telemedicine use and outpatient care during the COVID-19 pandemic in the United States. Health Affairs, 40(2), 349-358. https://doi.org/10.1377/hlthaff.2020.01786

Shigekawa, E., Fix, M., Corbett, G., Roby, D. H., & Coffman, J. (2018). The current state of telehealth evidence: A rapid review. Health Affairs, 37(12), 1975-1982. https://doi.org/10.1377/hlthaff.2018.05132