A telehealth note in Australia must carry everything an in-person note carries, plus the details that prove the session happened the way you claimed it: the modality (video or phone), the date, start and finish times, who attended, the patient's location, the identity and consent checks you made, and anything that went wrong with the technology.
That extra layer is not busywork, because two regulators reach into the same note. Ahpra's telehealth guidance, updated on 7 October 2025, lists actions you must take during a virtual consultation, and your record is the only durable evidence you took them. Medicare then decides which item number the session qualifies for on facts your note either captures or loses.
The clinical content itself does not change. Presentation, mental state, interventions, risk and plan belong in a telehealth note exactly as they would in a room, and our guides to clinical notes and mental health progress notes cover that layer. What changes is the surrounding evidence: in a consulting room, identity, privacy of the setting and physical presence are self-evident, and over video or phone none of them are.
What must you record at the start of a telehealth session?
Ahpra's guidance for practitioners who provide virtual care sets out what practitioners should do at the beginning of a consultation. Each item translates directly into a line in your record:
- Identity. The guidance says to "identify all practitioners present and confirm the identity of the patient". Record how you confirmed it, not just that you did.
- What to expect. You must explain what to expect from a telehealth consultation, "including if the consultation will be recorded or an AI scribe used".
- Informed consent. Consent must be obtained "including for the use of any AI scribes". Note the date consent was given and its scope.
- Clinical appropriateness. You must assess, and regularly re-assess, whether telehealth is safe and clinically appropriate, "or whether good care can only be provided by the patient and practitioner being in each other's physical presence". A note that never revisits this looks like a decision made once and forgotten.
- The patient's environment. You must ensure the patient is somewhere that "adequately protects privacy and confidentiality", consider whether anyone can overhear, and confirm the patient consents to that. This is the line most notes omit entirely.
- Limits of the technology. If technology means you cannot provide the service, you must advise the patient and help them access alternative care.
For the session itself, the guidance is blunt: practitioners must "ensure they maintain clear and accurate records of the consultation, in accordance with relevant legislative and any other requirements". Afterwards, handover or follow-up, and with consent informing other treating practitioners, belong in the record too.
What does Medicare require a telehealth note to show?
This is where most guidance stops short, and where the specifics are unusually concrete. MBS explanatory note MN.7.4, which governs focussed psychological strategies services, states that eligible practitioners "must keep contemporaneous notes of the consultation including documenting the date, time and people who attended".
Then comes the sentence worth reading twice: "Only clinical details recorded at the time of attendance count towards the time of the consultation. Other notes or reports added at a later time are not included."
Read that against a time-based item. If you claim an item requiring at least 50 minutes, the clock runs on clinical detail recorded during the attendance, so notes written up that evening do not extend the consultation for item purposes. For anyone who batches notes at the end of the day, that is a real exposure.
The general standard sits in note GN.15.39. To be adequate, a record must clearly identify the patient, contain a separate entry for each attendance with the date the service was rendered, provide clinical information adequate to explain the type of service, and be comprehensible enough that another practitioner relying on it can effectively continue the patient's care. To be contemporaneous, it should be completed at the time the service was rendered "or as soon as practicable afterwards".
MN.7.4 adds a duty that sits outside the note but inside your file: the treating allied health professional "must also retain the referral for 2 years (24 months) from the date the service was rendered", separate from clinical record retention, which runs far longer. Our guide to how long to keep clinical records in Australia sets out those periods by jurisdiction.
Does the modality decide which item number you claim?
Yes, and that is precisely why modality has to be in the note. Under Better Access, in-person, video and phone are different items with different descriptors, and the descriptor is what your record has to support.
For a registered psychologist providing focussed psychological strategies, item 80110 requires the service be provided "individually and in person" in consulting rooms for at least 50 minutes. The video equivalent, item 91170, is the same service "by video attendance" at the same minimum duration and the same schedule fee of $119.45. Shorter video attendances of at least 20 but less than 50 minutes fall under item 91169, and phone attendances have their own items, 91183 and 91184, on the same duration split. Clinical psychologists have a parallel set under psychological therapy services.
So three facts select the item: modality, duration, and whether the service was individual. A note that says "session held" with no times and no mention of video or phone cannot substantiate the item claimed.
Group services are stricter again. MN.7.4 confirms group therapy by video is only claimable where the patient is in a Modified Monash Model area 4 to 7 at the time and at least 15 kilometres by road from the practitioner, and neither party may travel to satisfy that distance. The patient's location is an eligibility fact, not optional detail. Our guide to group therapy notes covers the participant and duration evidence those items also demand.
How should you document consent for an AI scribe?
Ahpra's October 2025 update named this explicitly, listing "gaining informed consent, especially when using any supporting technologies like AI scribes" among good telehealth practice, and its separate guidance on using artificial intelligence in healthcare reinforces that the practitioner remains accountable for the output.
Record three things: that you explained the tool, that the patient consented before any recording began, and that you reviewed and corrected the generated note before it was filed. The last matters most, because the clinician owns the accuracy of the note regardless of what produced the draft. We cover the regulatory position in AI guidance for health practitioners in Australia.
Consent is not permanent either. If you switch tools, or a patient who consented to a scribe in the room now joins by video from a shared house, revisit it and note that you did.
Where does privacy law come into a telehealth note?
Telehealth raises two privacy questions in-person work does not. The first is security: APP 11 requires reasonable steps to protect personal information from misuse, interference, loss and unauthorised access, and your video platform, recordings and scribe transcripts are all in scope.
The second is where the data goes. APP 8 "outlines the steps an APP entity must take to protect personal information before it is disclosed overseas", and plenty of video and AI note tools process data offshore, which makes platform choice a privacy decision rather than an IT one. APP 5 then governs telling patients about collection at the point it happens, which for telehealth clients usually means intake, covered in our psychology intake assessment guide.
What do you write when the technology fails?
Dropouts, frozen video and calls that revert to phone are ordinary events, and they change both the clinical and the billing picture. Record what failed, when, how long the interruption lasted, what you did, and whether the session continued, moved to phone or was abandoned.
If a video session becomes a phone session, that is potentially a different item, and only the note will show it. If a session ends early, the duration you can substantiate changes with it. Ahpra also requires you to advise the patient and arrange alternatives where technology prevents you providing the service, so the record should show that conversation happened.
What does a compliant telehealth note look like?
The following is illustrative only and does not describe a real client.
Nothing in that block is decorative. Each line answers a question a regulator, an auditor or a colleague picking up the file would otherwise have to guess at.
What are the common mistakes?
- No start and finish times. "Approximately an hour" is not a record of an eligibility fact.
- Modality left implicit. If the note does not say video or phone, the item claimed is unsupported.
- Writing the whole note afterwards. Only clinical detail recorded at the time counts towards the consultation time.
- No environment check, and consent recorded once then never revisited. A new tool, a new modality or a changed setting each warrant a fresh line.
PractaLuma is AI-native practice management software for Australian mental-health practices, and telehealth is where that structure earns its keep: modality, times and consent captured as fields rather than prose, with the AI scribe drafting clinical content into the clinical note for you to review before filing. See the full feature set and current pricing.
Frequently asked questions
Does a phone session count as telehealth for Medicare? Phone attendances have their own MBS items under Better Access, separate from video and in-person items and with their own duration thresholds, so the note must make clear which modality was used.
Do I need written consent for telehealth? Ahpra's guidance requires informed consent, specifically including consent for AI scribes, but does not prescribe a form. What matters is a dated record of what was explained and what the patient agreed to. Written consent at intake plus a session-level note is a defensible approach.
Can I record a telehealth session? Only with informed consent obtained beforehand, after explaining that the session will be recorded. Recording rules also vary between states and territories, so check the requirements where you and the patient are located.
How long do I keep telehealth records? The same retention periods as any other clinical record, which differ by state and by patient age. Better Access referrals carry a separate 2-year retention duty under MN.7.4.
This article is general information for practitioners, not legal, clinical or billing advice. MBS item requirements and professional obligations change. Check the current MBS Online item descriptors, Ahpra's telehealth guidance and your National Board's code of conduct before relying on any of it.