Since the COVID-19 pandemic, telehealth has become an essential part of midwifery care in Washington State, offering flexibility for prenatal check-ins, postpartum follow-ups, lactation support, and client education. While these virtual visits can improve access and convenience, they also come with specific charting requirements that differ from in-person encounters.

Washington State law, along with HIPAA and professional documentation standards, sets clear expectations for what must be recorded during a telehealth visit. These requirements protect client privacy, support quality care, and provide legal protection for midwives if questions arise later. Yet, many midwives are unaware of the exact elements they’re expected to document, and it’s easy to miss details like noting the client’s location or obtaining and recording telehealth-specific consent.

In this post, we’ll walk through the Washington State rules, the key elements every telehealth chart should include, and common mistakes to avoid. We’ll also share a sample chart note and a checklist you can use to streamline documentation while staying compliant.

Regulatory & Legal Framework for Telehealth Documentation in Washington State

In Washington, telehealth visits are governed by a combination of state statutes, administrative rules, and federal privacy laws. For midwives, these requirements apply whether the visit is prenatal, postpartum, educational, or for urgent consultation.

1. State Statutes

Washington’s telemedicine requirements are found in RCW 70.41.230 and related laws, which require providers to:

• Obtain and document the client’s verbal or written consent to receive care via telehealth before the visit begins.
• Explain the risks, limitations, and alternatives to telehealth.
• Document the type of technology used (video, audio-only, or other HIPAA-compliant platform).
• Record the location of both the client and the provider during the encounter.
• Verify the client’s identity, especially for initial visits.

Washington also has a separate statute for audio-only telemedicine (RCW 48.43.735), which still requires informed consent and documentation of the mode of delivery.

2. Administrative Rules

WAC 182-501-0300 outlines telemedicine and telehealth requirements for providers who bill Medicaid. Even if you don’t bill Medicaid, these standards are considered best practice. Key documentation requirements include:

• Consent: Written or verbal consent for telemedicine services, obtained and documented in the medical record before the service.
• Service modality: Whether the encounter was via interactive audio/visual telemedicine or audio-only telemedicine.
• Location: Where the client was located and where the provider was located during the visit.
• Platform: Technology used, ensuring compliance with privacy and security requirements.
• Provider and participant identification: Names and roles of everyone present during the visit.
• Limitations: Any limitations in the examination due to the telehealth format and steps taken to address them.

3. HIPAA Privacy & Security

All telehealth encounters must protect protected health information (PHI) under HIPAA:

• Use HIPAA-compliant technology unless the client is fully informed of its limitations and consents.
• Secure all stored and transmitted data.
• Avoid public Wi-Fi and document any technical issues that may affect privacy.

4. Payer Requirements

If you bill Medicaid, commercial insurance, or managed care organizations, be aware of payer-specific documentation rules, which may require:

• Start and stop times for time-based codes
• Documentation of all services, counseling, and education provided
• Correct ICD-10 and CPT/HCPCS codes for telehealth

Bottom line:

In Washington, a complete telehealth chart note must capture not only the clinical details of the encounter but also the telemedicine-specific elements spelled out in RCW 70.41.230, RCW 48.43.735, and WAC 182-501-0300. Failing to document these items can result in compliance issues, claim denials, or liability exposure.

Required Elements for Telehealth Visit Documentation

To be compliant in Washington — and to protect both client and provider — your telehealth chart note must include both standard clinical documentation and telemedicine-specific elements:

1. Date, Time, and Duration of the Visit

• Date and start/end times (especially important if billing Medicaid or other time-based codes).

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2. Consent for Telehealth

• Document verbal or written consent obtained before the visit per RCW 70.41.230 and WAC 182-501-0300.
• Include a brief note on what was covered in the consent discussion:
  • Nature of the telehealth visit
  • Potential limitations compared to in-person care
  • Risks, benefits, and alternatives
  • Privacy considerations
  • Right to stop or request in-person care at any time

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3. Type of Telehealth Modality Used

• Specify whether the encounter was:
  • Interactive audio-visual telemedicine
  • Audio-only telemedicine (per RCW 48.43.735)
  • Secure messaging/other HIPAA-compliant platform for asynchronous communication

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4. Client and Provider Locations

• Document the physical location of the client (city/town and state) and provider location during the visit.
• Note if the client was at home, at a clinic, or another location.

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5. Identity Verification

• Record how the client’s identity was verified (e.g., name/DOB confirmation, visual recognition, client ID if applicable).

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6. Participants in the Visit

• List all individuals present during the visit, including:
  • Partner/family/support people
  • Interpreter (name and role)
  • Students or assistants

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7. Clinical Content (SOAP or Equivalent)

• Subjective: Client’s concerns, reported symptoms, relevant history.
• Objective: Observations possible via telehealth (appearance, demeanor, visible findings) and any self-reported data (e.g., home BP readings, fetal movement counts).
• Assessment: Your clinical impression based on available data.
• Plan: Care instructions, follow-up, referrals, and educational resources provided.

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8. Limitations of the Telehealth Format

• Note any parts of the exam that could not be completed remotely (e.g., no fundal height measurement) and how you addressed them (e.g., scheduled in-person follow-up).

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9. Technical and Privacy Considerations

• Document that a HIPAA-compliant platform was used, or that the client was informed of limitations if not.
• Record any technical issues that occurred and how they were handled.

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Pro tip:
Create an EHR template or paper checklist with these elements so they’re not overlooked. Missing even one (like location or consent) can result in a chart that’s noncompliant under Washington law.

Common Charting Mistakes to Avoid in Telehealth Visits

Even experienced midwives can unintentionally miss required telehealth documentation elements, especially when using templates designed for in-person care. Here are some of the most frequent pitfalls we see:

• Not documenting telehealth consent in detail.
• Omitting client and provider locations.
• Skipping identity verification, even for established clients.
• Failing to list all participants present.
• Using in-person templates without telehealth-specific fields.
• Not noting limitations of the remote format.
• Ignoring technical or privacy issues during the encounter.

Why this matters:

Incomplete telehealth notes can lead to Medicaid or insurance claim denials, audit findings, and liability exposure in the event of a complaint or adverse outcome. In Washington, missing documentation of consent, location, or modality is one of the top reasons telehealth claims are denied or flagged for review.

Best Practices to Streamline Telehealth Charting

Telehealth documentation doesn’t have to be time-consuming, but it does have to be thorough. By setting up systems and workflows that capture Washington’s required elements automatically, you can make compliance part of your routine rather than an afterthought.

1. Create or Customize a Telehealth Template in Your EHR

• Add required WA fields for consent, client/provider location, modality, identity verification, and limitations.
• Include automatic prompts for listing all participants and noting technical issues.
• If you use paper charts, create a dedicated telehealth visit form.

2. Build a Consent Script

• Keep a short, consistent consent script handy so you cover all required points at the start of every visit.
• Example: “Before we begin, I want to confirm you consent to this telehealth visit, understand the risks and benefits, and know you can stop at any time and request in-person care. Do you agree to proceed?”

3. Use a Pre-Visit Checklist

• Confirm client identity and location before starting.
• Verify they have a private, secure space for the visit.
• Check any equipment they’ll use to share home measurements (e.g., BP cuff).

4. Document as You Go

• Record consent, location, and participants immediately at the start of the chart note so you don’t forget later.
• Use shorthand or templates for common counseling topics, but avoid generic copy-paste for assessments and plans.

5. Integrate Client Self-Reporting

• Encourage clients to take vital signs or other measurements beforehand and send them via your secure platform.
• Clearly label them as client-reported in your note.

6. Note Limitations and Next Steps

• If you can’t complete an element of the physical exam, document the limitation and your plan to address it (e.g., “Unable to palpate abdomen; will assess at in-person visit on [date]”).

7. Train Staff and Students

• Make sure everyone who assists in telehealth visits understands WA-specific documentation requirements.
• Provide them with your telehealth charting checklist so details aren’t missed.

The goal is to make telehealth compliance automatic by embedding required elements into your charting process. This not only protects your license and billing but also ensures your chart tells the complete story of the visit.

Sample Telehealth Chart Note

Client Name: Jane Doe
DOB: 03/14/1995
MRN: 2025-042
Date of Visit: 08/14/2025
Start Time: 10:02 AM
End Time: 10:36 AM
Visit Type: Telehealth – secure, HIPAA-compliant video conference via [platform name]
Provider Name/Title: [Your Name], CPM, LM
Client Location: Home – Seattle, WA
Provider Location: Tacoma, WA (licensed in WA)
Other Participants: Client’s partner [name]; student midwife [name]
Identity Verification: Confirmed by name and date of birth; visually verified via video

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Consent

Verbal consent obtained for telehealth visit after explaining:

• Nature of telehealth visit
• Potential limitations compared to in-person care
• Risks, benefits, and alternatives
• Privacy protections and HIPAA compliance
• Right to stop or request in-person care at any time
  Client verbalized understanding and agreed to proceed.

Chief Complaint / Reason for Visit

Routine 34-week prenatal check-in; client reports feeling well, no acute concerns.

Subjective

• Denies vaginal bleeding, loss of fluid, contractions, or decreased fetal movement.
• Reports occasional mild lower back discomfort, relieved by rest and stretching.
• Reports good fetal activity.
• Home BP reported by client this morning: 112/70 mmHg (automatic cuff).
• Weight reported by client per home scale: 182 lbs.

Objective

• Client alert, oriented, no acute distress.
• Breathing unlabored, speech clear.
• Abdomen observed as gravid, consistent with stated gestational age.
• No visible swelling in face or extremities noted via video.
• Fundal height and fetal heart tones not obtained (limitation of telehealth); client instructed on when to schedule in-person evaluation if concerns arise.

Assessment

G2P1 at 34 weeks, low-risk pregnancy, normal subjective findings for gestational age. No signs or symptoms of complications.

Plan

1. Continue routine prenatal self-care.
2. Encouraged hydration, light stretching, and posture support for back discomfort.
3. Reviewed warning signs requiring immediate contact or in-person evaluation:
   • Vaginal bleeding
   • Decreased fetal movement
   • Persistent headache or vision changes
   • Sudden swelling
4. Next in-person prenatal visit scheduled for 08/28/2025.
5. Educational resource link emailed: “Comfort Measures in the Third Trimester.”

Telehealth-Specific Notes

• Required WA telehealth elements documented: consent, modality, location, identity verification, participants, and limitations.
• Technical connection stable; no interruptions noted.
• Visit conducted in compliance with HIPAA and WA State telemedicine rules.

Signature:
[Electronic signature]
[Name], CPM, LM
08/14/2025 – 11:02 AM

Telehealth Charting Checklist

(Based on RCW 70.41.230, RCW 48.43.735, and WAC 182-501-0300)

*Use this checklist for every telehealth visit to ensure complete and compliant documentation.

Before the Visit

☐ Verify the platform is HIPAA-compliant (or obtain client consent for non-HIPAA-compliant platform).
☐ Confirm client identity (name and DOB).
☐ Document physical location of client and provider.
☐ List all participants (partner, interpreter, student, assistant).
☐ Obtain and document verbal or written telehealth consent, including:

• Nature of telehealth visit
• Risks, benefits, and alternatives
• Limitations of remote care
• Privacy considerations
• Right to request in-person care at any time

During the Visit

☐ Record start and end time of the encounter.
☐ Note telehealth modality (interactive video, audio-only, secure messaging).
☐ Complete SOAP note with client-reported data clearly labeled.
☐ Note any limitations of the telehealth format and how they will be addressed.

After the Visit

☐ Document any technical or privacy issues that occurred and how they were resolved.
☐ Ensure chart note includes all telehealth-specific elements required by WA law.
☐ Submit billing codes and modifiers as required by payer for telehealth services.
☐ Securely store any client-uploaded files or photos.

Pro Tip:
Keep this checklist integrated into your EHR template or printed and clipped to your workspace. Missing even one required element — especially consent, location, or modality — can make the note noncompliant under Washington law.

Conclusion

Telehealth is here to stay in Washington midwifery care, and so are the documentation requirements that come with it. By capturing every legally required element and clearly recording the clinical details of your visit, you’re not just meeting compliance standards — you’re protecting your clients, your practice, and your license.

Complete, accurate telehealth notes also provide a clear record if questions arise later, whether from a payer audit, a client inquiry, or a legal claim. As a JUA policyholder, proper charting is one of your strongest risk management tools.

Now is the time to review your telehealth charting process.

• Check your EHR templates — do they include consent, location, modality, and limitations?
• Train your staff and students on what must be documented.
• Use the checklist provided in this post to make compliance automatic.

The goal isn’t just to “meet the rules” — it’s to create a complete, accurate, and defensible record that reflects the quality, safety, and professionalism of midwifery care in Washington State.

Have questions or tips about telehealth charting? Share them in the comments — your insight can help strengthen documentation practices across our midwifery community.

The information provided through this activity is for educational purposes only. This information is intended to provide general guidelines for risk management and those involved in claim process. It is not intended and should not be construed as legal or medical advice.