Documenting the Recovery Journey in Progress Notes

Documenting the Recovery
Journey in Progress Notes
Essential Skills for Providers
Learning Objectives
Identify the reasons for skillful progress
Define medical necessity.
Demonstrate understanding of the basic
rules and principles of writing progress
The definition of a progress note
Progress Notes are
a brief written
description in the
client record each
time services are
The Value of Progress Notes
Progress notes provide a record of the
consumer’s recovery journey.
The notes outline the work being done:
what’s helped, what’s not worked, ideas to
Notes facilitate communication and
Progress notes keep team members
informed so that coordination is possible.
Progress Notes and Accountability
Progress notes are part of a legal
document – the chart.
The chart can be subpoenaed.
 Progress notes are the basis for knowing
what was done, by whom and when.
 Make sure you include consultations, with
other providers as well as your supervisor.
Progress Notes and the Legal
If it ain’t
documented, it didn’t
Progress Notes and Supervision
Progress notes are used as a
supervisory tool.
Progress notes form a record of your work
with client’s in their recovery.
 Supervisors use progress notes to see what
you’ve been doing.
 Writing good progress notes is an essential
professional skill.
Progress Notes and Billing
Progress notes establish one component
of the basis for medi-cal billing.
Accountability for Billing
Every note
you write is
potentially a
bill to the
Compliance Laws
Elimination of fraud
and abuse in
 Requires systems to
put policies and
procedures in place
to monitor and
correct any
What is “medical necessity”?
Specifies the criteria for
medical reimbursable
There are three criteria
Allowable diagnoses
Impairment in
functioning criteria
Medical Necessity: Diagnosis
Not all mental health diagnoses qualify.
 Licensed clinicians evaluate and
diagnose individuals coming into our
 Non-licensed professionals document
observations of symptoms and behaviors
that substantiate the diagnosis.
Medical Necessity: Impairment in
Functioning Criteria
A significant
impairment in an
important area of life
functioning OR
 A probability of
deterioration in an
important area of life
Important Areas of Life Functioning
That Can Become Impaired
Danger to self/others
Activities of daily
Medical Necessity:
Intervention Criteria
The focus is to address the identified
 The expectation is that it will benefit the
consumer by
significantly diminishing the impairment
or preventing significant deterioration in an
important area of life functioning
The condition would not be responsive to
physical healthcare-based treatment
Identifying Functional Impairments
Where is Medical Necessity
Identified in the Chart?
Criteria are evident throughout the
Annual assessment
 Treatment Plan Goals and Interventions
 Progress Notes
The Role of the Direct Service
To observe and document evidence of medical
necessity within the individual’s scope of
 Non-licensed professionals often see behavior
and know of issues the consumer is
experiencing which other professional staff
may be unaware of.
 Documentation of symptoms, functional
impairments and results of interventions are
key to providing evidence of medical
What’s wrong AND What’s right
Medical necessity
focuses on the
diagnosis, symptoms
and impairments that
create barriers for the
As we do our work, we
focus on
Back to Basics: What do progress
notes include?
Name of client
 Date of service
 Location
 Time involved
 What services were provided
 Signature, including discipline
Progress Note Basics
Every progress note must be legible
 When you make a mistake, cross out
with ONE LINE, write “error”, and write
your initials.
Progress Note Basics
Notes must accurately reflect the activity,
location and time for each service
 Time includes
Time spent in travel to deliver the service
 Providing the service
 Documenting the service
Progress Note Basics
Big Time = Big Note
adequate description in the note of what
took so much time.
Progress Note Basics
Notes must reflect services based on the
current assessment and client plan.
 Notes billable to Medi-Cal must
demonstrate medical necessity of
services delivered.
 Not all services are billable – and may
still be exactly the right service to
Best Practice Documentation
For a service to be billable, it requires
identification of a mental health service.
 You must describe the mental health
issue as you also document the
cultural/diversity and person-centered
elements of service delivery.
In documenting services
Have you examined your rationale for
the services you’re providing?
Show your thinking.
Use language that demonstrates these
mental health issues.
Progress Note Basics
Notes must not include other consumer’s
Progress Note Basics
Include documentation of coordination
and collaboration, e.g., referrals.
 Include documentation of any changes to
the treatment and recovery plan.
 Include date of follow-up care,
appointments or discharge summary.
Progress Note Basics
Write as if the client is looking over your
Using respectful and recovery-oriented
Time Lines
Best practice is to write the note as soon
as possible after delivering a service.
Each county determines the exact
standard timeline for writing notes.
Quiz Time!!!

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