Are you tired of writing notes? Use our AI Scribe.
Date/Time and Duration - ensure this accurately represents the Face-to-Face time spent with the client not just the autopopulated “60 minutes” by TN.
Ensure the code is correct - 90791 is for new client intakes
(90837 = 60min, 90832 = 30min, 90847 = couples/families - these would only be used if the client is transferred from another clinician and the intake session has been completed within six months (or one year for Anthem))
Location matches with the note - Teletherapy (note includes location and confidentiality)
Ensure participants accurately reflect everyone who participated during the session.
It cannot be vague. The required criteria are as follows: major symptoms, situations in which it is worse or better, what has been tried to improve it, what worked in the past, if this is a recurrence.
Assessment - ASQ or Columbia Short Version.
Safety plan (If SI in the past 30 days) - make sure a copy of the safety plan is added to TN file (and must be signed by the client). Statement that the clinician provided the client with emergency/crisis information
Statement that the clinician reviewed the disclosure statement and other intake paperwork (confidentiality, mandated reporting, etc.)
PCP (coordination of care) - declined or agreed. If agreed - ROI given (change the check box in TN in the client’s patient information tab).
If teletherapy session - a statement about location and ability to speak confidentially
If working with a minor - include a statement about discussing the importance of including parents
History of Present Problem
Demonstrate medical necessity through answering the following questions: (1) onset of symptoms, (2) symptoms, (3) frequency, (4) duration, (5) severity, and (6) impact on functioning
Trauma
If client reports child abuse (even if they are over 18) include statement about if the abuse was reported previously, if not will it be reported now, and if it will not be reported now, why not?
Substance Use
Include the family history of substance use (not just the clients)
Spiritual/Cultural Factors
If there is a spiritual or religious affiliation document if this will have an impact treatment or not.
Initial goal (can include proposed interventions before the treatment plan is developed).
Recommended type and frequency of services (Ex: Individual weekly sessions)
Whether referrals are needed for outside services
Person-centered information, along with information demonstrating the full criteria in the DSM, is met. Do not just copy and paste the DSM language.
The client reports...The client endorses the following symptoms, which meet the diagnostic criteria for…..
Criteria for each diagnosis if multiple diagnoses (Ex: PTSD - client-centered list of symptoms, MDD - client-centered list of symptoms)