Keeping Progress Notes on Headway (For Colorado Providers)

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This article contains information that is helpful for Headway providers. If you are a client and have questions, check out our support articles for clients!

 

Headway now offers insurance-compliant progress notes templates. These templates can reduce the amount of time you spend trying to get your notes right and, if filled out correctly, can leave you feeling more confident that your progress notes meet payer compliance standards. 

 

 

What makes a note compliant? 

In order to meet progress note compliance requirements, your notes should always include:

  • Provider Name
    • Full name & NPI / License Number at the top of notes, or in the header
  • Client Name & DOB
    • This must be listed on every page
  • Date of Service
  • Session length (All timed codes must include the length in minutes.)
    • This must have the exact start and exact end time
  • Length of Therapy (If therapy was provided in addition to evaluation and management, time of therapy must be included.)
  • Session Location (Include whether virtual or office address. If performing telehealth services, indicate the virtual platform.)
    • If held virtually, include a statement indicating that the session took place "via an interactive audio and video telecommunications system".
  • Signature and Credentials of Provider (Use /s/ to indicate an electronic signature on Headway. Example: /s/ John Q. Public, LCSW.)
    • With the date that the notes were signed

While some of this information may be repetitive with what Headway collects automatically in your calendar, insurance companies require these details to be included directly in your notes.

 


How do I use templates on the Headway platform? 

When confirming a session, you will see a progress notes section. From there, you will be given a few options. To use one of our progress note templates:

  1. Select “fill out template”.
    Screen_Shot_2022-12-06_at_7.43.55_AM.png
  2. Under “template”, you can select an option from our template offerings using the dropdown menu.
    • These templates include intake and follow up templates, a combined medication management / talk therapy template for prescribers, and a free text SOAP template.
      Screen_Shot_2022-12-06_at_7.44.03_AM.png
  3. Once a template has been selected, fill out all applicable fields.
    • Our system will let you know when you’ve missed a required field!
    • You will also be given the option to pre-fill the template based on a previous session.
  4. You’ll be given the option to save your work and “complete progress note later" or "sign note".
    Screen_Shot_2022-12-06_at_7.46.21_AM.png 
    • If you select "complete progress note later", you can save all the information you've inputted, and come back to finish it when you're ready. 
    • If you select "sign note", the session will be confirmed and your progress note will be completed & attached to the session! 

 


What templates do I have to choose from?

Currently, we offer the following options:

  • Intake – Prescriber
    • Initial assessment note for prescriber completing an E/M service
  • Follow up – Prescriber
    • Progress note for prescriber completing an E/M Service
  • Intake – Therapy Only
    • Initial assessment note for therapy
  • Follow up – Therapy SOAP
    • Progress note for therapy
  • Follow up – EM with Therapy Add-On
    • Progress note for prescriber completing an E/M service with a therapy service
  • Intake / Progress – Free Text SOAP
    • Generic SOAP template for initial assessment or progress note

 

Which template is best for me? 

 

Intake – Prescriber

Best for... Prompts include... Intended for use with codes...
  • Prescribers
  • Initial psychopharmacology appointment focused on medication management and prescribing

 

Follow up – Prescriber

Best for... Prompts include... Intended for use with codes...
  • Prescribers
  • Follow-up psychopharmacology appointment focused on medication management and prescribing

 

Intake – Therapy Only

Best for... Prompts include...
  • Initial assessment appointment for therapy

 

Follow up – Therapy SOAP

Best for... Prompts include...
  • Follow-up therapy appointment
  • Utilizes the SOAP structure (subjective, objective, assessment and plan)

 

Follow up – EM with Therapy Add-On

Best for... Prompts include... Intended for use with codes...
  • Follow-up appointment focused on both psychopharmacology and therapy

 

Intake / Progress – Free Text SOAP

Best for... Prompts include...
  • Therapy appointment (intake or follow-up)
  • Utilizes the SOAP structure (subjective, objective, assessment and plan)

 

  

Disclaimer

  

This document is intended for educational purposes only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific   requirements.   

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