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

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 Medical Necessity: Intervention Criteria

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!!!