on the mark progress notes who what when where why how progress notes

ON THE MARK ON THE MARK Progress NotesProgress Notes

WhoWhat WhenWhereWhy How

Progress NotesProgress Notes



There are many reasons fordocumentation. Among these are

1. to communicate with other practitioners. 2. to provide an accurate record for legal purposes.3. to document certain elements of the treatment process for payers.

The focus of this section is on providingdocumentation for Medicaid payment. It is notmeant to be all inclusive or to take the place ofa thorough understanding of Medicaid’s rulesand regulations or codes of professional ethics,pertaining to record keeping.



We hope to provide a method that will simplify the writing of progressnotes for your Medicaid Consumers.



Answer these Questions




Who - was present ?

The actual practioner must include complete credentials that document the provider qualifies for MHP or BHRS status with their legible signature.

For examplePat Doe, MS, LPC

or Chris Doe, BA.

Who ?Who



What – did the consumer say and

do in the session?

What was the consumer’s general response to the session?

What progress was made toward theconsumer’s goals since the last session?

What new problems were identified?

What

What?



Remember: What – did the consumer say and

do in the session?

Provide examples of behaviors and/orquotes. Although an assessment of whatwas observed is OK, it must be accompanied by a record of

What?

what was actually said and done.



Assure that the services provided are age and developmentally appropriate and provide extradocumentation for any service that mightbe deemed questionable (IE, I.T. with aconsumer with profound mentalretardation or social skills training with a3 year old).



When – was the session?

Include the date and the time thesession started and stopped.

When?

When



Where - was the session held?

Document the setting was confidential.

Where

Where?



Why – was the session needed?

What treatment problems, goals and or objective(s) were addressed?

Why

Why?



How – were the problems addressed?

What methods were used?

For Individual Counseling – What theoretical approach?

How

How?



Some Services RequireSpecial Documentation



Group TherapyWho – was present? How many

consumers and how many practitioners were present? (Limited to 8 consumers for adults, 6 for residents of nursing or ICF/MR facilities and children. The group may not consist solely of related individuals.)

Why – was the session needed? The focus of the group must be documented.



Group rehabilitationWho – was present?

How many consumers and how many practitioners were present? (The maximum staffing ratio must be 14 consumers to 1 staff for Adults and 8 to 1 for children. Countable staff must be appropriately trained in behavior management / intervention techniques such as MANDT or CAPE).

Why - was the session needed? The skills that were taught must be documented.



Group rehabilitation (cont)What – skills were taught? The skills taught must include one or more of the following:

Independent living.

Self care.Social skills (development or redevelopment).Lifestyle changes.Recovery principles and practices. Basic living skills



For all group services a list of participants must be maintained.



Family Therapy Who – was present? Document the names of the participants.

What – was the focus of the session?

The focus must be on the Problems, Goals andFamily therapy objectives of the identifiedconsumer.



Individual rehabilitationWhat – skills were taught? The skills taught must include one of thefollowing educational and supportive services:

Independent living.Self care.Social skills (development or redevelopment).Lifestyle changes.Recovery principles and practices.



Individual Rehabilitation with a family

How – will the specialized skills trainingbenefit the identified consumer?

Parenting skills training must be for thepurpose of treating the identified consumer’sdisorder. The skills must relate to one or more treatmentobjectives and specifically designed to help theParents with the special emotional needs of the

child.



Treatment PlanningWho – was involved in the

treatment planning? Include, the specific involvement of each person.

Treatment Plan ReviewWho – was involved in the

treatment planning? Include, the specific involvement of each person.



Medical Review

Who – performed the review? Medical review’s must be performed by a RN orPA under the supervision of a physician. Thenote should document if the physician ispresent or available for consult.

What – was the focus of the review? Only the following are appropriate:1. Current medication2. The consumer’s response to the medication3. The consumer’s compliance with medication4. Vital signs, including B/P, pulse and

respiration.



Crisis InterventionWho – was present? A crisis intervention must be a face to faceintervention

Why – was the service required? Emergency service must be to resolve an acuteemotional situations that could result in asignificant functional impairment such asSuicidal or Homicidal Ideations or Psychotic aEpisode.

The Consumer’s Level of Function at the time ofthe crisis. must be recorded. (i.e., the GAF).



The crisis intervention service can not be reimbursed

if the consumer was receiving a mentalhealth service at the time .



Now for some

EXAMPLESEXAMPLES



12 year old SED consumerDIAGNOSIS: Bereavement (Secondary toMajor Depressive Disorder Recurrent, Severewithout psychotic features.)

PROBLEM 1: Grief/loss related to recent death of mother.

GOAL 1: Begin the process of acceptance of the loss.

OBJECTIVE 1A: Identify and process 3 ways the loss has affected life.



WHEN

5/30/02 (0900-1000) -



WHO

5/30/02 (0900-1000) – Consumerand I



WHERE

5/30/02 (0900-1000) – Consumerand I met in my office



HOW

5/30/02 (0900-1000) – Consumerand I met in my office for IndividualGrief Therapy.



WHY

5/30/02 (0900-1000) – Consumer and I

met in my office for Individual GriefTherapy. The focus of today’s sessionwas on the ways how his loss haseffected his life (Obj 1A).



WHAT5/30/02 (0900-1000) – Consumer and I met inmy office for Individual Grief Therapy. Thefocus of today’s session was on the ways his loss has effected

his life (Obj 1A). Becomingtearful, he stated he cries several times eachday when he thinks of her. He discussed severalthings he missed about her, but became mosttearful when he discussed going to bed at night, becausehis mother used to read to him. Bobby stated he feltbetter having discussed his feelings. He stated he feelshe is crying less and is able to maintain in school mostdays which he feels is good progress and no newproblems. He also reports a decrease in aggressivebehavior at school.



WHEN (Next Appointment)5/30/02 (0900-1000) – Consumer and I met inmy office for Individual Grief Therapy. Thefocus of today’s session was on the ways his loss has effected his life (Obj 1A). Becomingtearful, he stated he cries several times eachday when he thinks of her. He discussed severalthings he missed about her, but became mosttearful when he discussed going to bed at night, becausehis mother used to read to him. Bobby stated he feltbetter having discussed his feelings. He stated he feelshe is crying less and is able to maintain in school mostdays which he feels is good progress and no new problems. He also reports a decrease in aggressivebehavior at school. Our next session will be 2 weeks(6/13/02 at 0900)



5/30/02 (0900-1000) – Consumer and I met inmy office for Individual Grief Therapy. Thefocus of today’s session was on the ways howhis loss has effected his life (Obj 1A). Becomingtearful, he stated he cries several times eachday when he thinks of her. He discussed severalthings he missed about her, but became mosttearful when he discussed going to bed at night, becausehis mother used to read to him. Bobby stated he feltbetter having discussed his feelings. He stated he feelshe is crying less and is able to maintain in school mostDays which he feels is good progress and no new problems. He also reports a decrease in aggressivebehavior at school. Our next session will be 2 weeks(6/13/02 at 0900) J.Q. Therapist



WHO (Signature)5/30/02 (0900-1000) – Consumer and I met in my officefor Individual Cognitive Therapy. The focus of today’ssession was on the ways how his loss has effected hislife. Becoming tearful, he stated he cries several timeseach day when he thinks of her. He discussed severalthings he missed about her, but became most tearfulwhen he discussed sleeping alone. The consumer statedhe felt better having discussed his feelings. Our nextsession will be 2 weeks (6/13/02 at 0900).

J.Q. Therapist, MSW, LSW-CMSW, LSW-C^̂

Credentials

WHO (Signature)5/30/02 (0900-1000) – Consumer and I met in my office for IndividualGrief Therapy. The focus of today’s session was on the ways how hisloss has effected his life (Obj 1A). Becoming tearful, he stated he criesseveral times each day when he thinks of her. He discussed severalthings he missed about her, but became most tearful when hediscussed going to bed at night, because his mother used to read tohim. Bobby stated he felt better having discussed his feelings. Hestated he feels he is crying less and is able to maintain in schoolMost Days which he feels is good progress and no new problems. Healso reports a decrease in aggressive behavior at school. Our next

session will be 2 weeks (6/13/02 at 0900)

J.Q. Therapist, MSW, LSW-CMSW, LSW-C^̂

Credentials



Adult SMI ConsumerDIAGNOSIS: Paranoid Schizophrenia

PROBLEM 1: Poor Hygiene that increases social isolation.

GOAL 1: Client will bathe regularly and wear clean clothing.

OBJECTIVE 1A: Client will learn and practice 5 methods to insure good personal hygiene.



WHEN

5/30/02 (0900-1000) – It is a good practice to note travel

time, if appropriate, as it is not compensable. For this example, it is not necessary.



WHO

5/30/02 (0900-1000) – Consumerand I, along with 3 other group members



WHERE

5/30/02 (0900-1000) – Consumerand I, along with 3 other group members met in Group Room A.



HOW

5/30/02 (0900-1000) – Consumerand I, along with 3 other group members met in Group Room Afor Group Rehabilitation.



WHY

5/30/02 (0900-1000) – Consumerand I, along with 3 other group members met in Group Room Afor Group Rehabilitation. The focus of today’sgroup was dental care (Obj 1A).



WHAT5/30/02 (0900-1000) – Consumer and I, along with 3other group members met in Group Room A for GroupRehabilitation. The focus of today’s group was dental

care (Obj 1A). The group was taught 3 essentials ofgood dental care, brushing, flossing and regular checkups. Bill stated his gums bleed when he brushes and heis afraid he will lose his teeth. He also stated hehad increased flossing to 2 or 3 times per week. Billcontinues to have difficulty attending to the group, heseems to be distracted by the voices he hears. Heseemed proud he had made some progress on takingcare of his teeth and denies any new problems.



WHEN (Next Appointment)5/30/02 (0900-1000) – Consumer and I, along with 3other group members met in Group Room A for GroupRehabilitation. The focus of today’s group was dental

care (Obj 1A). The group was taught 3 essentials ofgood dental care, brushing, flossing and regular checkups. Bill stated his gums bleed when he brushes and heis afraid he will lose his teeth. He also stated hehad increased flossing to 2 or 3 times per week. Billcontinues to have difficulty attending to the group, heseems to be distracted by the voices he hears. Heseemed proud he had made some progress on takingcare of his teeth and denies any new problems.

The next group will be 2 weeks (6/13/02 at 0900).



WHO (Signature)5/30/02 (0900-1000) – Consumer and I, along with 3other group members met in Group Room A for GroupRehabilitation. The focus of today’s group was dental

care (Obj 1A). The group was taught 3 essentials ofgood dental care, brushing, flossing and regular checkups. Bill stated his gums bleed when he brushes and heis afraid he will lose his teeth. He also stated hehad increased flossing to 2 or 3 times per week. Billcontinues to have difficulty attending to the group, heseems to be distracted by the voices he hears. Heseemed proud he had made some progress on takingcare of his teeth and denies any new problems. The next groupwill be 2 weeks (6/13/02 at 0900).

J.Q. Therapist



WHO (Signature)5/30/02 (0900-1000) – Consumer and I, along with 3 othergroup members met in Group Room A for Group Rehabilitation.The focus of today’s group was dental care (Obj 1A). Thegroup was taught 3 essentials of good dental care, brushing,flossing and regular check ups. Bill stated his gums bleed whenhe brushes and he is afraid he will lose his teeth. He alsoStated he had increased flossing to 2 or 3 times per week. Billcontinues to have difficulty attending to the group, heseems to be distracted by the voices he hears. He seemed proud he had made some progress on taking care of his teethand denies any new problems. The next group will be 2 weeks

(6/13/02 at 0900). J.Q. Specialist, BS^̂

Credentials



Using a Progress Note “Form”

The same components are necessary for both narrative style group rehab notes and for a “fill in the blank” form.



Example - “Fill in the Blank” Form

Describe what the consumers actually did during the activity _______________________________________________________________________________________

Activity Start Time ____ End Time_____ Ratio ___ Travel time to: ____ from: ____

Goals Addressed with Curriculum _________________________________________ ________________________________________________________________________________________________________________________________________

Progress Toward Objective(s) ___________________________________________________________________________________________________________________________________________________________________________________

Ct Response ______________________________________________________________________________________________________________________________

New Problems ________________________________________________________

__________________________ ____________ Staff Signature Credentials Date



Activity: 16 consumers and 2 staff attended the grocery shopping activity that had been preplanned this AM.

Describe what the consumers actually did during the activity

Who and What


WhoWhat WhenWhereWhy HowActivity Start Time 12:30 End Time 2:30 Ratio 8 to 1 Travel time to: 12:05-12:30 from: 2:30-3:00 OR

Began the Food Shopping Curriculum at IGA at 12:30.The session ended in the IGA parking lot at 2:30. Consumer to staff Ratio - 8:1

The Activity Start and End Time should not reflect travel time. The travel time section is not mandatory, but can help clarify the actual time the consumer was in treatment.(Ratio = Staff to Consumer Ratio)

When


WhoWhat WhenWhereWhy HowGoals Addressed with Curriculum – Curriculum wassuccessful at reinforcing the benefits of his goal of improving his financial planning and his goal of eating more nutritious foods.

Goal addressed explains how the activity and the curriculum relates to the consumer’s treatment plan

Why and How



Progress Toward Objective - Consumer learned 1 Money Management skill and1 Food Planning Skill.He was able to use a budget and plan food purchases in advance. He also chose healthy foods.He was able to maintain his budget and food plan, despite many temptations, without redirection. Thisis the first time the client has been able to do so.

How did the curriculum address the client’s goals andobjectives and what progress was made?

How, What, Why



Consumer Response simply states what the client says about the current session.

Consumer Response – Bill states he is very proudof himself and can’t wait to eat the plums he bought.

What and Who



New Problems – Client reports he has had an increasein auditory hallucinations. He was asked if he neededto see the physician or his therapist, but he said hecould wait until his next session.

New Problems would include any new problem orchange in problem status.

What and Who


WhoWhat WhenWhereWhy HowD.O. Gooder, MSW, LSW-C 04-11-02 Staff Signature Credentials Date

Signature must be legible and include degreeand license. Signature must be dated at the timeit is signed.

Who and When



Case Management Progress Notes

Remember - “CASE MANAGEMENT SERVICES ARE PROVIDED TO ASSIST CONSUMERS IN GAINING ACCESS TO NEEDED MEDICAL, SOCIAL, EDUCATIONAL AND OTHER SERVICES ESSENTIAL TO MEETING BASIC HUMAN NEEDS”.

CM Progress notes must reflect this.



CM Notes MUST reflect

Referral

Linkageand/or

Advocacy



Referral is defined as:

To direct to a source for help or information.

A referral does not require direct action with the resource.



Linkage is defined as:

To connect with or as if with a link: linked the rings to form a chain. Synonym = join

A link requires direct action with the resource. The CM forms the link between the consumer and the resource.



Advocacy is defined as:

To speak, plead, or argue in favor of. Synonym = Support

Advocacy requires more than simple linkage of the consumer and the resource. The CM must take action or the consumer will be unable to successfully access the resource.



The documentation must identify that the consumer NEEDS a particular resource and that the service (referral, linkage, advocacy) provided is required for the consumer to be successful in accessing the resource.



Who is present?Client?Family? (Must relate to consumer’s TxP)

Community Resource?

Remember to sign and date the progress note.

Include your credentials.



What did the consumer say and

do in the session (provide examples)?

What was the consumer’s general response to the session?



What progress was made

toward the consumer’s goals since the last session?

What new problems were identified?



What methods were used?

(Referral, Link, Advocate)

Specifically -What referral was made?What link was established?What advocacy was accomplished?



When was the session? Include the date and the time the session started and

stopped.



Where - was the session held?

Document the setting was confidential.



Why – was the session needed?

What treatment problems, goals and or objective(s) were addressed?



How – were the problems addressed?

How was the referral made?Gave consumer the phone number

How was linkage performed?Called the resource for the consumer and made the appointment.

How was advocacy performed?Called the resource for the consumer and explained his appropriateness for the service. Made the appointment.



317:30-5-248. Documentation of records

All outpatient behavioral health services must be reflected bydocumentation in the patient records.

1) Individual, group and family counseling and individual and group rehabilitative treatment services must include the following:

A) date;B) start and stop time for each session;C) signature of the therapist;D) credentials of therapist;E) specific problems addressed (problem must beidentified on master treatment plan);

http://www.ohca.state.ok.us/Provider/Rules/provrules.htm



F) methods used to address problem(s);G) progress made toward goals;H) patient response to the session or intervention; andI) any new problem(s) identified during the session.

2) In addition to the items listed in (1) of this subsection:A) Crisis Intervention Service notes must also include:

(i) a detailed description of the crisis; and(ii) level of functioning assessment.

B) For each Group rehabilitative or counseling session a list of participants and facilitating BHRS or MHP must be maintained.

C) For medical review, vital signs must be recorded.

http://www.ohca.state.ok.us/Provider/Rules/provrules.htm



Karen Frensley. MBS, [email protected]

Debbie Spaeth, LMFT, LPC, [email protected]

Van Rhodes, MSW, [email protected]



RememberWhoWhat WhenWhereWhy How

The End

on the mark progress notes who what when where why how progress notes

Documents

mark progress notes

writing of progress

special documentation

medicaid consumers

consumers goals

extra documentation

treatment problems

consumers general response