Documenting the Recovery Journey in Progress Notes

Report
Documenting the Recovery
Journey in Progress Notes
Essential Skills for Providers
Learning Objectives

Identify the reasons for skillful progress
notes.

Define medical necessity.

Demonstrate understanding of the basic
rules and principles of writing progress
notes.
The definition of a progress note

Progress Notes are
a brief written
description in the
client record each
time services are
provided.
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
try.
Notes facilitate communication and
coordination.

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
System

If it ain’t
documented, it didn’t
happen.
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
Federal
Government.
Compliance Laws

Elimination of fraud
and abuse in
Medicaid/Medicare
funding.
 Requires systems to
put policies and
procedures in place
to monitor and
correct any
problems.
What is “medical necessity”?


Specifies the criteria for
medical reimbursable
services
There are three criteria



Allowable diagnoses
Impairment in
functioning criteria
Intervention-related
criteria
Medical Necessity: Diagnosis
Not all mental health diagnoses qualify.
 Licensed clinicians evaluate and
diagnose individuals coming into our
system.
 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
significant
deterioration in an
important area of life
functioning
Important Areas of Life Functioning
That Can Become Impaired





Occupational
Social
School
Danger to self/others
Activities of daily
living
Medical Necessity:
Intervention Criteria

The focus is to address the identified
impairment
 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
Exercise
Identifying Functional Impairments
Where is Medical Necessity
Identified in the Chart?

Criteria are evident throughout the
documentation
Annual assessment
 Treatment Plan Goals and Interventions
 Progress Notes

The Role of the Direct Service
Provider

To observe and document evidence of medical
necessity within the individual’s scope of
practice.
 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
necessity.
What’s wrong AND What’s right


Medical necessity
focuses on the
diagnosis, symptoms
and impairments that
create barriers for the
individual.
As we do our work, we
focus on


reducing/eliminating
barriers
strengths
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.

NEVER USE
WHITE-OUT.
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
OR
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
provide.

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
names.
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
shoulder.

Using respectful and recovery-oriented
language
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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