Progress Notes. 15.1. CONTRACTOR shall create progress notes for the provision of all SMHS services provided under this Agreement.
15.2. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.
15.3. Progress notes shall include all elements specified in BHIN 22-019, whether the note be for an individual or a group service.
15.4. CONTRACTOR shall complete progress notes within three business days of providing a service, with the exception of notes for crisis services, which shall be completed within 24 hours.
15.5. Providers shall complete a daily progress note for services that are billed on a daily basis, such as residential and day treatment services, if applicable.
Progress Notes. 1) The Contractor shall ensure that progress notes describe how services provided reduced impairment, restored functioning, or prevented significant deterioration in an important area of life functioning outlined in the client plan. Items that shall be contained in the client record related to the beneficiary’s progress in treatment include:
a) Timely documentation of relevant aspects of beneficiary care, including documentation of medical necessity;
b) Documentation of beneficiary encounters, including relevant clinical decisions, when decisions are made, alternative approaches for future interventions;
c) Interventions applied, beneficiary’s response to the interventions and the location of the interventions;
d) The date the services were provided;
e) Documentation of referrals to community resources and other agencies, when appropriate;
f) Documentation of follow-up care, or as appropriate, a discharge summary; and
g) The amount of time taken to provide services; and
h) The signature of the person providing the service (or electronic equivalent); the person’s type of professional degree, licensure, or job title.
Progress Notes. Progress notes are required each day TBS is delivered and must include a comprehensive summary covering the time that services were provided. In the progress note, the time of the service may be noted by contact/shift. As with other MHP progress notes, staff travel and documentation time are included with direct service time; on call time may not be claimed. The following must be clearly documented:
a. Occurrences of specific behaviors and/or symptoms that jeopardize the residential placement or prevent transitions to a lower level of placement;
b. Significant interventions identified in the Client Treatment Plan;
Progress Notes. 20.5.1 Contractor shall create progress notes for the provision of all DMC-ODS services provided under this Agreement.
20.5.2 Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.
20.5.3 Progress notes shall include all elements specified in BHIN 22-019, whether the note be for an individual or group service, and shall include:
20.5.3.1 The type of service rendered
20.5.3.2 A narrative describing the service, including how the service addressed the client’s behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors)
20.5.3.3 The date that the service was provided to the beneficiary
20.5.3.4 Duration of the service, including travel and documentation time
20.5.3.5 Location of the client at the time of receiving the service
20.5.3.6 A typed or legibly printed name, signature of the service provider and date of signature 20.5.3.7 ICD-10 code
Progress Notes. 3.7.1. CONTRACTOR shall create progress notes for the provision of all SMHS services provided under this Agreement.
3.7.2. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.
3.7.2.1. Should more than one provider render a service, either to a single member or to a group, at least one progress note per member must be completed. The note must be signed by at least one provider. The progress note shall clearly document the specific involvement and duration of direct patient care for each provider of the service.
3.7.3. Progress notes for all non-group services shall include:
3.7.3.1. The type of service rendered.
3.7.3.2. A brief description of how the service addressed the member’s behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors).
3.7.3.3. The date that the service was provided to the member.
3.7.3.4. Duration of the patient care for the service.
3.7.3.5. Location/place of service.
3.7.3.6. A typed or legibly printed name, signature of the service provider and date of signature.
3.7.3.7. A brief summary of Next steps, including, but not limited to, planned action steps by the provider or by the member, collaboration with the member, collaboration with other provider(s) and any update to the problem list as appropriate.
Progress Notes. County requires a progress note section in the client record and that a client record contain the following information:
A. Timely documentation of relevant aspects of client care.
B. Mental health staff/practitioners’ documentation of client encounters, including relevant clinical decisions and interventions.
C. All entries must include the signatures of the person providing the service, professional degree or licensure or, job title.
D. All entries must include the date service(s) were provided.
E. Documents referrals to community resources and other agencies, when appropriate.
F. Documents for follow-up care or, as appropriate, a discharge summary.
G. Documentation of progress towards Client Plan goals.
H. Progress notes written by an unlicensed staff who does not meet minimum educational and experiential standards must be co-signed by an approved category of staff. The record and signature shall be legible. If the signature is not legible, the writer’s name shall be printed legibly in proximity to the signature. If Contractor uses an electronic signature, a copy of the policy and procedure must be submitted to the County, meet the minimum qualifications as set forth in state and federal regulations, and be reviewed and approved by County prior to acceptance. Electronic signatures may also be applied to the Daily Transactions to be certified by practitioners.
Progress Notes. Progress notes are required each day TBS is delivered and must include a comprehensive summary covering the time that services were provided. In the progress note, the time of the service may be noted by contact/shift. As with other MHP progress notes, staff travel and documentation time are included with direct service time; on call time may not be claimed. The following must be clearly documented:
i. Occurrences of specific behaviors and/or symptoms that jeopardize the residential placement or prevent transitions to a lower level of placement;
ii. Significant interventions identified in the Client Treatment Plan;
iii. Progress in stabilizing behaviors and/or symptoms by changing or eliminating maladaptive behaviors and replacing them with adaptive behaviors.
Progress Notes. 20.5.1 Contractor shall create progress notes for the provision of all DMC-ODS services provided under this Agreement.
20.5.2 Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.
20.5.2.1 Should more than one provider render a service, either to a single member or to a group, at least one progress note per member must be completed. The note must be signed by at least one provider. The progress note shall clearly document the specific involvement and duration of direct patient care for each provider of the service.
20.5.3 Progress notes for all non-group services shall include:
20.5.3.1 The type of service rendered
20.5.3.2 The date that the service was provided to the member.
20.5.3.3 Duration of direct patient care for the service.
20.5.3.4 Location/place of service.
Progress Notes. A. County requires a progress note section in the client record and that a client record contain the following information:
1. Timely documentation of relevant aspects of client care.
2. Mental health staff/practitioners’ documentation of client encounters, including relevant clinical decisions and interventions.
3. All entries must include the signatures of the person providing the service, professional degree or licensure or, job title.
4. All entries must include the date service(s) were provided.
5. Documents referrals to community resources and other agencies, when appropriate.
6. Documents for follow-up care or, as appropriate, a discharge summary.
7. Documentation of progress towards Client Plan goals.
B. Progress notes written by unlicensed staff who do not meet minimum educational and experiential standards must be co-signed by an approved category of staff. The record and signature shall be legible. If the signature is not legible, the writer’s name shall be printed legibly in proximity to the signature. If Contractor uses an electronic signature, a copy of the policy and procedure must be submitted to the County, meet the minimum qualifications as set forth in state and federal regulations, and be reviewed and approved by County prior to acceptance. Electronic signatures may also be applied to the Daily Transactions to be certified by practitioners.
Progress Notes a. Contractor shall create progress notes for the provision of all DMC-ODS services provided under this Agreement.
b. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description.
c. Progress notes shall include all elements specified in BHIN 22-019, whether the note be for an individual or group service, and shall include:
i. The type of service rendered
ii. A narrative describing the service, including how the service addressed the client’s behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors)
iii. The date that the service was provided to the beneficiary
iv. Duration of the service, including travel and documentation time
v. Location of the client at the time of receiving the service
vi. A typed or legibly printed name, signature of the service provider and date of signature
vii. ICD-10 code
viii. Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code ix. Next steps, including, but not limited to, planned action steps by the provider or by the client, collaboration with the client, collaboration with other provider(s) and any update to the problem list as appropriate.
d. Contractor shall complete progress notes within three business days of providing a service, with the exception of notes for crisis services, which shall be completed within 24 hours.
e. Contractor shall complete a daily progress note for services that are billed on a daily basis, such as residential and inpatient services, if applicable.
f. When a group service is rendered by the Contractor, the following conditions shall be met:
g. A list of participants is required to be documented and maintained by the Contractor.
h. If more than one provider renders a group service, one progress note may be completed for a group session and signed by one provider. Contractor shall ensure that in this case, the progress note clearly documents the specific involvement and the specific amount of time of involvement of each provider during the group activity, including documentation time.
