Behavioral Health Telehealth Note Template

Behavioral health is the one category of telehealth that survives past 2027 largely intact, and it carries a documentation requirement of its own. This template pairs the virtual encounter record — patient location, licensure, modality, consent, others present — with a clinical section built for psychiatry at a distance: interval history, the mental status examination domains, named instruments with scores, and a risk assessment that includes confirming the patient's physical location, because a safety plan is only actionable if you know where the patient is.

The section that makes this template different is the in-person visit tracker. Under section 1834(m), an in-person non-telehealth visit within 6 months before the first mental health telehealth service becomes effective after December 31, 2027, and thereafter an in-person service is required within 12 months of each mental health telehealth service, with limited exceptions. Those visits may be furnished by a same-specialty clinician in the same group if the treating clinician is unavailable. Patients who began receiving mental health telehealth at home on or before December 31, 2027 count as established and skip the prior 6-month visit, needing one in-person visit every 12 months after that date. The template records which side of that line each patient sits on now, so nobody is reconstructing eligibility from old charts in 2028. Optimized for use with Sully.ai's AI medical scribe, it helps streamline note-taking and improve clinical efficiency.