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How to Document Online Therapy Sessions

Online therapy has moved from a minority option to a standard part of clinical practice. Many psychologists and psychotherapists now see half or more of their patients by video call, and that raises concrete documentation questions that don't always have obvious answers.

What should a note for an online session include that a face-to-face note doesn't? How do I handle informed consent remotely? What are my obligations under GDPR and the LOPDGDD when data travels over the internet? This article tackles those questions in practical terms.

Why online therapy requires its own documentation approach

In a face-to-face session, many things happen naturally: the patient walks into the room, there's a shared physical space, clinical observations include posture, movement, physical presence. Online, the frame is different — and the documentation needs to reflect that.

Online therapy also introduces variables that don't exist in a physical setting: connection quality, the patient's environment, external interruptions, the possibility that someone else is present just off-screen. All of that can be clinically relevant and deserves to be in the record.

Assessing suitability for online therapy

Not every patient is suited to online therapy. Before offering this modality, it's worth assessing and documenting:

  • Active suicidal ideation with a plan — this may require in-person sessions for crisis management.
  • Severe psychotic or dissociative presentations that make screen-based communication difficult.
  • The patient's technical capacity to maintain a stable connection and access a private space.

Documenting the suitability assessment protects the therapist and demonstrates clinical judgment.

Informed consent is always mandatory, but online therapy has specific considerations worth documenting explicitly:

What to include in consent for telehealth:

  • Confirmation that the patient has a private space available for sessions.
  • Understanding of the limits of confidentiality in a digital environment.
  • Crisis or emergency protocol, including the fact that the therapist may not be physically nearby.
  • The patient's physical location at the start of each session — recording it once isn't enough. If you need to contact emergency services, you need to know where the patient is at that moment.
  • What platform will be used and confirmation that the patient has been informed of its privacy terms.
  • Alternative procedure if the connection fails.

This consent can be signed with a simple electronic signature (for example, confirmation by email), which is legally valid for these purposes in Spain. It must be saved and retrievable.

What to include in an online session note

In addition to the usual clinical content, a well-written online session note includes:

Contextual framing information:

  • Platform used (Zoom, Teams, Google Meet, etc.).
  • Any relevant technical issues (connection drops, audio problems, delays) and how they affected the session.
  • Whether the patient was in a private space, and whether there were interruptions or signs that third parties were present.

Clinical observations adapted to the medium:

  • The screen limits non-verbal information: document what you were able to observe (facial expression, tone of voice, speech rhythm) and note any aspects you couldn't assess due to technical conditions.
  • Whether the patient showed notable behaviours related to the online frame (repeated disconnections, resistance to turning on the camera, a visibly chaotic or distracting environment).

Emotional state at the start and end: In online therapy it's especially important to document how the patient enters and leaves the session, since there's no physical transition. The patient goes from session to everyday life in seconds, and that can have clinical implications.

Privacy and GDPR in telehealth

GDPR and the LOPDGDD apply with the same force to online therapy as to face-to-face therapy. The digital medium adds layers of risk that need active management. The official psychology professional associations in Spain have published specific recommendations on the practice of telepsychology that are worth consulting.

Key points to review:

  • Video call platform: Is it subject to GDPR? Are the servers in the EU or in third countries? Some popular platforms operate servers in the United States, which may require additional safeguards.
  • Digital clinical notes: They must be encrypted and stored in systems with appropriate guarantees. A Word file on your laptop desktop is not sufficient.
  • Communication with patients: Unencrypted email is not appropriate for sharing sensitive clinical information.

A good practice is to periodically review the digital tools you use in your practice and ensure you have a signed Data Processing Agreement (the legal contract that obliges the provider to protect your data) with every provider that processes your patients' data.

A clear frame protects everyone

Online therapy works best when the frame is explicitly agreed and documented. This includes the technical aspects (platform, crisis protocol, what to do if the connection drops) and the clinical ones (expectations, boundaries, differences from face-to-face work if any).

A well-documented frame doesn't just protect the therapist legally: it also gives the patient a sense of security and consistency that, in online therapy, can be harder to convey implicitly.

Clara works for both in-person and online sessions, generating complete clinical notes from each session. Try Clara free →