Documenting the Recovery Journey in Progress Notes

1. Documenting the Recovery Journey in Progress Notes Essential Skills for Providers

2. Learning Objectives • Identify the reasons for skillful progress notes. • Define medical necessity. • Demonstrate understanding of the basic rules and principles of writing progress notes.

3. The definition of a progress note • Progress Notes are a brief written description in the client record each time services are provided.

4. 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.

5. 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.

6. Progress Notes and the Legal System • If it ain’t documented, it didn’t happen.

7. 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.

8. Progress Notes and Billing • Progress notes establish one component of the basis for medi-cal billing.

9. Accountability for Billing Every note you write is potentially a bill to the Federal Government.

10. 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.

11. What is “medical necessity”? • Specifies the criteria for medical reimbursable services • There are three criteria • Allowable diagnoses • Impairment in functioning criteria • Intervention-related criteria

12. 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.

13. 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

14. Important Areas of Life Functioning That Can Become Impaired • Occupational • Social • School • Danger to self/others • Activities of daily living

15. Medical Necessity: Intervention Criteria • 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

16. Exercise Identifying Functional Impairments

17. Where is Medical Necessity Identified in the Chart? • Criteria are evident throughout the documentation • Annual assessment • Treatment Plan Goals and Interventions • Progress Notes

18. 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.

19. 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

20. Back to Basics: What do progress notes include? • Name of client • Date of service • Location • Time involved • What services were provided • Signature, including discipline

21. 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.

22. 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

23. Progress Note Basics • Big Time = Big Note OR adequate description in the note of what took so much time.

24. 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.

25. 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.

26. 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.

27. Progress Note Basics • Notes must not include other consumer’s names.

28. 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.

29. Progress Note Basics • Write as if the client is looking over your shoulder. • Using respectful and recovery-oriented language

30. 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.

31. Quiz Time!!!