Progress notes

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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!

 

 

Is there a recommended template for progress notes?

A popular template for progress notes is SOAP (Subjective, Objective, Assessment, Plan). Using this template is optional, so long as your notes follow our Payer's notes guidelines! Details on common code guidelines can be found in our article "CPT and diagnosis codes". This includes guidance on the following CPT codes:

  • 90832-90838
  • 90791
  • 90792
  • 90839/90840
  • E&M Codes 99203-99205, 99213-99215
  • 90785

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.

Below, you'll find guidelines of how to keep notes in a streamlined way that is effective for insurance companies and for clients.

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.

 

Is there a template I can copy and paste for my own use?

Please feel free to use one of the templates below by highlighting and then copying and pasting the content. You can find both a copiable SOAP template and copiable DAP template for your reference.

  SOAP Template

Provider Name:
Provider NPI:
Client Name:
Client Date of Birth:
Date of Service:
Exact start time and end time:
*Length of Therapy: If therapy is provided in addition to evaluation and management, time of therapy must be included in addition to “session length.”
Session Location: (virtual/ office address) Indicate the virtual platform, if performing telehealth services. Specify "Zoom" or "Doxy.me."
Diagnoses (in words):

Subjective notes: (may include, but not limited to)
Current mental status:
Progress/comparison to last session:
Reported changes in condition:
Activity level:
Stress levels:
Current complaints:

Objective notes: (may include, but not limited to)
Reasoning for diagnoses selection:
Symptoms:
Client’s appearance:
Orientation (place, time, situation):
Relevant observations about the client during the session:
Test results/diagnostic data:
Recognition/review from other clinicians:
For prescribers: Continuing medication, changes to dosage, or new medications (or can be kept on separate Medication list):
(For prescribers: Allergies (or can be kept on separate Allergies list):
*if coding based on Medical Decision Making for Evaluation and Management Service, justify your level of Medical Decision Making in this section

Assessment:

Statement of medical necessity:
Assessment of client, session, and situation:
Clinical impressions related to factors such as mood, orientation, risk of harm:
Assessment of progress toward goals:

Plan:
Modality:
Plan for next session:
Plan to see new specialist:
Homework assignments:

Electronically signed by: /s/ (your name and credentials)
Note signed date:

  DAP Template

Provider Name:
Provider NPI:
Client Name:
Client Date of Birth:
Date of Service:
Exact start time and end time:
*Length of Therapy: If therapy provided in addition to evaluation and management, time of therapy must be included in addition to “session length.”
Session Location: (virtual/ office address) Indicate the virtual platform, if performing telehealth services. Specify "Zoom" or "Doxy.me."
Diagnoses (in words):

Data:
Current mental status:
Progress/comparison to last session:
Reported changes in condition:
Activity level:
Stress levels:
Current complaints:
Reasoning for diagnoses selection:
Symptoms:
Client’s appearance:
Orientation (place, time, situation):
Relevant observations about the client during the session:
Test results/diagnostic data:
Recognition/review from other clinicians:
(For prescribers) Continuing medication, changes to dosage, or new medications (or can be kept on separate Medication list):
(For prescribers) Allergies (or can be kept on separate Allergies list):
*if coding based on Medical Decision Making for Evaluation and Management Service, justify your level of Medical Decision Making in this section

Assessment:
Statement of medical necessity:
Assessment of client, session, and situation:
Clinical impressions related to factors such as mood, orientation, risk of harm:
Assessment of progress toward goals:

Plan:
Modality:
Plan for next session:
Plan to see new specialist:
Homework assignments:

Electronically signed by: /s/ (your name and credentials)
Note signed date:

 

What should my notes always include?

Your notes should always include:

  • Provider Name
  • Client Name
  • Date of Service
  • Session length (All timed codes must include the length in minutes.)
  • 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. For example, specify it it was "Zoom" or "Doxy.me.")
  • Signature and Credentials of Provider (Use /s/ to indicate an electronic signature on Headway. Example: /s/ John Q. Public, LCSW.)

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.

Notes should also include the following categories:

  • Subjective Notes
  • Objective Notes
  • Assessment
  • Plan
Subjective Notes

Subjective notes are reports of what your client tells you. This may include elements like:

  • Current mental status exam
  • Progress/comparison to last session
  • Reported changes in condition
  • Family/employment history
  • Disability status
  • Activity level
  • Social history
  • Current condition/complaint
  • Stress levels

Example:

"Client reports that they have been unable to focus at work."
Objective Notes

Objective notes are your reported findings as the provider. This may include elements like:

  • Diagnosis
  • Any test results/diagnostic data
  • Symptoms
  • Recognition/review from other clinicians
  • Client's appearance
  • Relevant observations about client during session
  • Orientation (place, time, situation)
  • Mood

Example:

"Client appeared neatly groomed and calm."
Assessment

The assessment is your clinical impression of the Subjective and Objective sections. This may include:

  • Assessment of client, session, and situation
  • Clinical impressions related to factors such as mood, orientation, risk of harm
  • Assessment of progress towards goals

Example:

"Client appears to understand the new goal."
Plan

The Plan section is your recommendation for future care. It may include:

  • Modality/procedure performed in the session
  • Plan for next session
  • Plan to see new specialist
  • Homework assignments
  • How new interventions will be implemented

Example:

"Client will take a 30 minute walk each day this week."

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.

 

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

Medical record documentation for CPT codes 90832 – 90838 must include the following:

  • Exact start and stop time, reported in the note separate from the appointment time
  • Modalities and frequency
  • Clinical notes for each encounter including:
    • Diagnosis
    • Symptoms
    • Focused mental status examination
    • Treatment plan, prognosis, and progress
    • Name, *signature, and credentials of person performing the service. (*use /s/ to indicate Signature on Headway)

Helpful tips on 90832-90838:

  • CPT codes 90832-90838 may be reported on the same day as codes 90486 or 90487 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.

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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