Common use of Progress Notes Clause in Contracts

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.