Common use of Progress Notes Clause in Contracts

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. 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: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.title.‌