Progress Note Cheat Sheet

Table of Contents
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Note Header

  • Date/Time and Duration - ensure this accurately represents the Face-to-Face time spent with the client not just the autopopulated  “minutes” by TN.
  • Ensure the code is correct - 90837 = 60min, 90832 = 30min, 90847 = couples/families
  • Location matches with the note - Teletherapy (note includes location and confidentiality)
  • Ensure participants accurately reflect everyone who participated during the session.

Risk Assessment

  • 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 signed by the client)
  • Statement that the clinician provided the client with emergency/crisis information

Symptom Description and Subjective Report

  • Demonstrate medical necessity for session (include client's current symptoms.
    • Frequency, Duration, Severity, Impact on Functioning
  • If teletherapy session - a statement about location and ability to speak confidentially (can also be in the additional notes section).

Objective Content

  • At a minimum - 3 and 3 rule - 3 client statements/shares and 3 clinician lead therapeutic interventions.  For notes that are 45 minutes (90834) and 30 minutes (90832) long - a 2 and 2 rule may be used.  For a 30 minute note that had a duration of 16 minutes - a 1 and 1 rule may be used (anything above 16 minutes needs to follow the 2 and 2 rule).  
  • Therapeutic interventions need to include the therapeutic value/benefit to the client (why) - (not just a list of interventions).
  • This needs to be a comprehensive, thorough, detailed description of what took place during the session and how it is aiding the client in reaching their treatment goals.

Interventions Used

  • This needs to match the interventions discussed in the objective content section.

Treatment Plan Progress

  • The therapist can include statements after “Progressing” to explain the progress - (type in how the client is progressing, maintained, regressed, etc).

Additional Notes/Assessment

  • A therapist can include statements about the client’s “progress” from the TP section.
  • If teletherapy session - a statement about location and ability to speak confidentially (can also be in the symptom description section).

Plan

  • It can include type of session (individual session), frequency when the next session will occur (could consist of the date of the next session), homework given, and plan for the next session.