Progress note training

Report
“The Basics You Need to Know”
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Leave nothing blank on the left side of the form that you are
required to fill out
◦ A blank space means you “Forgot” to complete that data entry
 Leaves the reviewer to guess at the information
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Always sign, date, and use your credentials (no abbreviations)
◦ Example:
 John Doe, MS, Senior Community Mental Health Practitioner
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Progress notes need to be dated the day the session was
provided, NOT the day it was written
◦ It is advisable to write your note within 24 hours of the session as to not
forget pertinent information
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Type your notes
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It is more legible
Write notes as a single paragraph
Do not leave spaces at the end of a sentence or skip line.
Check for spelling and grammatical errors
Draw a line from the last emptied line to the bottom of the page
 This prevents someone from “adding” to your note
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Use proper correction techniques
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You will need to know your treatment goals and objectives to write your
progress note
◦ Single line thru with initial and date above
◦ Be careful with dates… best to re-write the note if your date and time is incorrect
◦ NO WHITE OUT
◦ For your progress note to be billable it MUST be directly related to treatment provided
that is based on your treatment plan goals and objectives.
◦ In the event you identify a new problem that is not on your treatment plan or review,
make a note in your progress note that “new objective (or goal) has been identified
today and you be added to the treatment plan. The new objective (or goal) is as
follows…”
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When a new objective or goal is being added, either a treatment plan review or
addendum needs to be completed.
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The decision as to which document is completed is to be made during supervisor with the
Clinical Director
Only your client’s name can be identified in your progress note
◦ Confidentiality is an issue for non-clients as well. Siblings, parents, family, etc.
names cannot be in your note.
◦ Use descriptive language i.e. John’s youngest sister….
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The progress note must describe what the client
has done in the session (not what the clinician
has done)
◦ Remember this is a note to document details about how
treatment is or is not progressing with the client;
progress/lack of progress is based on the client and how
they are proceeding through treatment.
 The only section in the note that defines what the clinician
did is the Treatment Intervention section.
 That section will look like “Cognitive Behavioral Treatment”,
“Solution Focused,” Play therapy techniques”, etc.
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A good note uses the FPS “FAIRS format
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A quality note can be described as:
◦ Clear: good connection between the narrative;
treatment goals and objectives; and the
interventions
◦ Profession: no spelling or grammatical errors
◦ Has a good use of clinical language
◦ Legible
◦ Informative: Paints a picture of the session
◦ Describes progress of the specific goal and
objective addressed that day
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Your progress notes should not be word for
word the same from prior progress notes.
Doing this is Medicaid Fraud and can lead to
serious repercussions
When ever in doubt consult with your
Supervisor
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Clinicians should document EVERY encounter or
attempt at an encounter with your client and/or
family
◦ No documentation means it NEVER occurred
 Need to document all your attempts to provide the service
◦ Does not follow FAIRS format
◦ Need to indicate the purpose of the note:
 Document a telephone call
 Examples:
 Attempted to contact: “Clinician left a message stating..”
 Completed call: Indicate the details of the conversation and the
outcome
 Document a missed session
 Examples
 “Clinician canceled due to…”
 “Client canceled due to…”
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Progress note A notes:
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
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Progress note B notes:
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
______________________
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F : Focus (Goal & Objectives)
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A : Assessment (Appearance/ Mood/Etc)
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I: Intervention (Clinical terminology only)
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R: Response (Describes session & Progress)
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Subsequent Plan: (Frequency of session; goals
plan to address, etc.)
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Ensures that you identify the goal(s) and
objective(s) you are addressing in the first
line of your progress note
Prompts you to write/indicate the
intervention(s) that you choose to use
Prompts you to write the client’s response to
treatment and provide detail in how you used
your intervention to address the specific
goal(s) and objective(s)
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Identifies the goal(s) and objective (s) you
addressed during the current session.
Example:
Goal: Improve overall mood
Objective: Peter will identify 5 triggers that
lead to thoughts of hurting himself…
Can write in an abbreviated fashion like this:
“Goal 1b: Improve mood; id triggers to
thoughts of harm”
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You will practice writing goals & objectives from
your treatment plan/review following FAIRS
Generalized Anxiety D/O (15 yo female;
removed-foster home)
◦ Goal 2: “I don’t want to feel anxious all day” (increased
mood stability)
 Objective d: Nancy will identify at least 3 triggers of fear
response…
◦ Rewrite:
F)_____________________________________________________
_______________________________________________________
_______________________________________________________.
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Conduct D/O, childhood onset (6yo maleintact family)
◦ Goal 1: “I want to stop getting in trouble” (Increased
compliance)
 Objective c: Peter will comply with directions with no
more than 1 prompt from adult…
◦ Re-write: F)
__________________________________________________
__________________________________________________
__________________________________________________.
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Describes how the client presented during the session
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Appearance- Physical presentation of client
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Affect- behavior that expresses an emotion that changes alone with
current emotional states and situation 9as compared to mood which
describes emotion occurring over a long period of time)
Mood- A pervasive and sustained emotion that colors the perception of
the world. (In contrast to affect, which refers to more fluctuating
changes in emotional ‘weather” mood refers to a more pervasive and
sustained emotional “climate”)
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Behaviors- describe client’s willingness to cooperate or resist clinician
during the session
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Speech- describes communication style used during therapy sessions.
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You will practice here by describing a client’s presentation in a
session using the FAIRS format.
◦ Client is diagnosed with Generalized Anxiety D/O, 15 yo female; and is
recently reunited with bio mother after 3 years in a foster home.
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1. Choose 2 or more descriptive words for each using the
handout provided:
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Appearance: ____________________________
Affect: __________________________________
Behavior:________________________________
Mood: __________________________________
Speech: _________________________________
2. Write your description of client in a narrative format using 1 to
3 sentences.
◦ A) :
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
________________________________________________________________________.
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Therapeutic technique- identifies specific therapeutic
intervention (s) utilized during current session.
The technique must be one of the evidence-based practices
Only use if you are familiar with the technique
Self-educate to increase your knowledge of different
interventions
◦ Reframe from using only 1 type of intervention throughout the course of
tx.
◦ Need to use best interventions suited to treat the individual and the issues
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One of the biggest flaws observed in a progress note is the
incorrect use of a therapeutic technique
◦ Your progress note is not billable if your note shows that you are not
familiar with how to implement the technique you choose.
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Elements of the RESPONSE section:
◦ Descriptive narrative
 Highlights clinical information as it relates back to the
current treatment plan goal and objectives being addressed.
◦ Client- Centered
 Reflects what client is/has done during session (not what
clinician is doing).
 Incorrect: Clinician will complete worksheet with client
 Correct: Mark will complete worksheet with clinician
◦ Progress
 Addresses progress on specific objective(s) regularly (at least
twice per month; every session best practice)
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Future: Goal & Objective you plan to address
during next session
Example: “Continue to meet with David 2x
per week for intensive services. Review
homework assigned (see note for details of
assignment).”
CONGRATULATIONS!!!!!!!
You have successfully completed the
INTRODUCTION TO PROGRESS NOTE WRITING
Workshop

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