My initial struggles with documentation:

When I started working in telehealth nursing, I thought the hardest part would be getting used to the technology and video visits. The real challenge was something I didn’t expect: documentation.

In bedside nursing, documentation had a rhythm and pattern to it. I’d assess, I’d chart, and I’d move on. In telehealth, I felt more pressure.

I’d find myself feeling split in two. Part of me wants to stay fully present with the patient—look at them, listen, make them feel like I’m there in the room with them. But then there’s the other part of me, glancing at the screen, trying my best to capture every detail, worried about compliance, and accuracy. Some days I found myself typing more than talking. Other days, I focused more on the conversation and then was left scrambling afterward, trying to document everything I should have written down. Both ways left me feeling like I’d fallen short. I often questioned myself on if I asked the right questions or if I forgot to ask something. With triage, I had a set of questions that would appear on the screen based on the symptoms the patient reported but many of the questions did not fit the patient’s scenario. After each call I had templates to choose from to send a summary to the patient. All the summaries were generic and did not allow for personalization. This was another difficult adjustment as I was left wondering if the template I chose would be enough for the patient to understand when/if to call back.

Tips to Improve Telehealth Documentation:

• Prepare before the visit
  • Review the patient’s chart and past notes ahead of time (if possible)
  • Open the documentation template so you’re ready to type.
• Use templates and smart phrases
  • Build standardized templates for common visits (follow-ups, med refills, new assessments).
  • Use shortcuts or macros for frequently used phrases.
• Take shorthand notes during the call
  • Jot quick key words or phrases instead of full sentences.
  • Fill in the full chart immediately after the visit.
• Balance presence and charting
  • Let the patient know if you’ll be typing during the conversation, so they don’t feel ignored.
  • Pause to summarize what they’ve said out loud—it helps both the patient and your notes (this has helped me tremendously)
• Finish documentation right away
  • Complete documentation after the encounter. Do your best to avoid saying you will “come back later.” Details fade quickly.
  • Block out a few minutes between calls just for documentation.
• Leverage your EHR features
  • Use dropdowns, checklists, or auto-populated fields to save time.
• Stay organized
  • Keep a checklist of required fields to avoid compliance issues.
  • Highlight abnormal findings or follow-up items as you go.
• Practice self-compassion
  • Acknowledge that documentation in telehealth is different—and challenging.
  • Give yourself space to keep improving without expecting perfection.

These steps have helped me improve communication with patients and meet documentation requirements.