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!
Table of Contents
What is the purpose of a progress note?
What is the difference between progress notes and psychotherapy notes?
What makes a note meet insurance company standards?
Is there a recommended template for progress notes?
How do I use templates through Headway?
What templates do I have to choose from?
Which template is best for me?
How can I add an addendum to a progress note?
How does Headway keep data secure?
What is the purpose of a progress note?
During the first session, providers will complete a diagnostic evaluation of the client. From this evaluation, the provider develops a treatment plan with specific goals for the client. This plan creates a thread from the initial evaluation through the progress notes, where providers track how well the client is progressing toward these goals over time.
What is the difference between progress notes and psychotherapy notes?
Progress notes essentially communicate the important details of a client’s care and diagnosis and are a key element of a client’s medical records. They include the details of the session including session start and end time, treatment modalities, symptoms, progress toward goals, and plan. Progress notes are legally required for every session billed to insurance.
Psychotherapy notes are solely for the purpose of the provider who writes them. These notes include details that might help providers remember the specifics of a session, and are not intended to be seen by anyone else. Our platform is not meant for storing psychotherapy notes.
What makes a note meet insurance company standards?
In order to meet insurance standards, your notes should always include:
- Provider Name and Credentials
- 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.)
- We've included fields in the appointment confirmation to add actual start and stop times to better meet insurance standards
- 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.)
- Provider name and Credentials (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.
Headway now has progress note templates available that offer structure and support. 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 insurers' standards.
Is there a recommended template for progress notes?
Keeping notes that meet insurers' standards can be complicated. The templates outlined below offer structure and support for your notes so that you can focus on providing care. Using the structured templates is optional, so long as your notes follow our guidelines!
Details on common code guidelines can be found in our article "CPT and diagnosis codes".
Important
Progress notes are part of your clients' medical records. In accordance with HIPAA, they can request to see them anytime. With this in mind, language in the notes should be culturally sensitive, precise, and free of moral judgment. Avoid phrases like "I think" or "it seems" as well as absolutes like "always" and "never." If you quote a client directly — especially if they use language that is inappropriate for the note — make sure to use quotes around that section.
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:
- Select “fill out template”.
- 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.
- These templates include intake and follow up templates, a combined medication management / talk therapy template for prescribers, and a free text SOAP template.
- 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.
- You’ll be given the option to save your work and “complete progress note later" or "sign note".
- 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:
- Diagnostic eval: Medical services
- Initial assessment note for prescriber completing a diagnostic evaluation with medical services
- Progress note: Medical services
- Progress note for prescriber completing a follow up evaluation with medical services
- Intake: Therapy
- Initial assessment note for therapy
- Progress note: Therapy
- Progress note for therapy
- Progress note: Therapy and medical services
- Progress note for prescriber completing a follow up evaluation with medical services and therapy
- Progress note: SOAP
- Generic SOAP template for initial assessment or progress note
Which template is best for me?
Diagnostic eval: Medical services
- Prescribers
- Initial psychopharmacology appointment focused on medication management and prescribing
- Psychiatric review of systems, medical review of systems
- History (psychiatric, medical, allergies, medications, family psychiatric, substance use, and social)
- Mental status exam
- Test results
- Physical exam
- Risk Assessment
- Assessment and plan
- 99202-99205
- 99212-99215
- 90792
Progress note: Medical services
- Prescribers
- Follow-up psychopharmacology appointment focused on medication management and prescribing
- Psychiatric review of systems
- Medical review of systems
- Abbreviated history
- Mental status exam
- Test results
- Physical exam
- Risk Assessment
- Assessment and plan
- 99212-99215
Intake: Therapy
- Initial assessment appointment for therapy
- Psychiatric review of systems
- History (psychiatric, medical, allergies, medications, family psychiatric, substance use, and social)
- Mental status exam
- Test results
- Risk Assessment
- Assessment and plan
Progress note: Therapy
- Follow-up therapy appointment
- Utilizes the SOAP structure (subjective, objective, assessment and plan)
- Subjective
- Objective (mental status exam, test results)
- Risk Assessment
- Assessment and plan
Progress note: Therapy and medical services
- Follow-up appointment focused on both psychopharmacology and therapy
- Psychiatric review of systems
- Modality of therapy treatment used
- Focus of therapy
- Medical review of systems
- Abbreviated history
- Mental status exam
- Test results
- Physical exam
- Risk Assessment
- Assessment and plan
- 99212-99215
Progress note: SOAP
- Therapy appointment (intake or follow-up)
- Utilizes the SOAP structure (subjective, objective, assessment and plan)
- Subjective
- Objective (mental status exam, test results)
- Risk Assessment
- Assessment and plan
How can I add an addendum to a progress note?
After a progress note is completed and signed, changes cannot be made to the original note. If you need to add something to the note, you can make an addendum. Click here for more information about how to appropriately use addendums.
To add an addendum to the progress note:
- Select the applicable client from within the “Clients” tab in Sigmund
- Navigate to the “Clinical” tab
- Note: All client information below is fictional.
- Scroll down to the “Past confirmed sessions” section
- Find the session date for the applicable progress note and click the carrot to show the session details
- Click “View Progress Note”
- Click “Edit” to add the addendum.
- Once you have selected to “Edit” the note, you can add any necessary additional details.
- Note: Addendums are used as a supplement to your original note, not as a replacement. Do not edit or delete any previously entered information.
You do have the option to upload a document instead of editing the note directly. If you choose to upload a document, be sure it has the following information:
- Date
- Includes patient identifying information
- Provider signature and license
Note: Addendums are used as a supplement to your original note, not as a replacement.
- Click “Submit Addendum” in the lower right hand corner to save and update the note.
What about progress notes for CPT codes 90832-90838?
The psychotherapy service codes 90832-90838 include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of informants in the treatment process.
CPT Codes 90832-90838 describe psychotherapy for the individual client, although times are for face-to-face services with client and may include informant(s). The client must be present for all or a majority of the service.
In reporting Psychotherapy services, choose the code closest to the actual time:
- Less than 16 minutes, not reported
- 16 to 37 minutes, 90832 or 90833*
- 38 to 52 minutes, 90834 or 90836*
- 53 minutes or more, 90837 or 90838*
*90833, 90836 and 90838 – these are psychotherapy add-on codes performed with E/M service. 90837 notes must include explicit documentation of medical necessity if used for a client more than once a week.
Helpful tips on 90832-90838:
- CPT codes 90832-90838 may be reported on the same day as codes 90846 or 90847 when the services are separate and distinct.
- Use CPT codes 90839 and 90840 when psychotherapy is provided to a client in a crisis state.
- Use 90785 in conjunction with codes 90832-90838 when the diagnostic evaluation includes interactive complexity services.
Limitations:
Psychotherapy services are not considered reasonable and necessary when documentation indicates:
- Client has dementia with severe enough cognitive defect to prevent establishment of a relationship with the therapist.
- Client with severe and profound mental retardation. Severe mental retardation is defined as an IQ 20-34 and profound mental retardation is defined as an IQ under 20.
- Treatment primarily included teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.
- Family therapy sessions with client whose emotional disturbance would be unaffected by changes in patterns of family interactions (i.e. a comatose client).
- Psychotherapy codes should not be used when an E/M code would be more appropriate.
- Psychotherapy services should not be reported for Activities of Daily Living (ADL) training or socialization activities.
How does Headway keep data secure?
We’re trusted with individuals’ most sensitive information, and take protection very seriously. We’ve built a secure data infrastructure and platform, maintain SOC 2 and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. Headway does not sell or upload any data to third party publishers.
Am I required to keep documentation on Headway?
You’re not required to use our templates or notes system, but it is required that you’re keeping notes for every session and that you produce them promptly (within three business days at most) of a request. If this is your preference, please select “Note saved elsewhere”.
If you do want to add your documentation on Headway, we make it a bit simpler through guided templates.
Am I able to export my client documentation?
Yes, contact us and we can provide a secure export of notes or treatment plans you’ve uploaded or written on Headway.
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.
