Applies to: ✅ Counselors, ✅ NPs
Psychotherapy/Psychiatry Notes (Intakes, Treatment Plans, Progress, Termination Notes, etc.) must be written within 72 hours of the session date of service and/or their schedule interval (e.g., Treatment plans must be updated every 5 months). Ideally, they should be written within 24 hours.
W2 Counselors whose sessions lack notes and the DOS occurred 7+ days ago will immediately be placed on a Performance Improvement Plan (PIP). This plan will provide the counselor with 14 days to update all session notes within 72 hours of the service date. The PIP will typically be sent 1-3 days after the pay period ends. The PIP is a step to aid clinicians in prioritizing note writing and getting caught back up in order to avoid further corrective action steps.
After the 14-day PIP period, counselors are expected to comply with their notes all being caught up to the 72-hour expectation window. If a counselor has not met the requirements, they will face corrective action, which could lead to possible termination if the counselor does not become compliant with the 72-hour note writing policy.
Despite meeting the PIP requirements, the counselor's eligibility for an annual pay raise might result in a diminished increase or even no raise at all. Moreover, receiving multiple PIPs within a year, even if each is satisfied, may lead to a decrease in the counselor's hourly wage.
Admin reserves the right to implement the above-mentioned steps at their discretion.
When notes are written after the 72-hour rule, they are delayed in being sent to insurance, which in turn delays the response from insurance, whether the claim is paid or denied. This can cause harmful outcomes for clients whose insurance denies the claim or whose insurance has been lost, and the client is now responsible for the entire bill for that session (and possibly additional sessions).
Going beyond the three-day time frame can raise doubts about the accuracy of your memory, especially if your notes come under scrutiny during legal proceedings. It's important to remember that being questioned about your documentation is a standard part of the legal process aimed at ensuring the reliability of recorded information. Writing your notes within the three-day window provides an added layer of protection.
New clinicians are given a 30-day grace period where notes are not expected to be written in the 72-hour timeframe due to the demands of learning OC expectations. After 30 days, all employees are to adhere to the 72-hour timeframe for note writing or become eligible for the following action steps.
ACA Code of Ethics: Section A.1.b. Records and Documentation