Increase Your Confidence in Writing Progress Notes
Written by Leslie S. Tsukroff, MSW, LCSW
Founder and Executive Director of Leslie S. Tsukroff, Inc.
A version of this question repeatedly comes up on professional listservs, in Facebook posts and during my workshops focused on documentation and progress notes.
Question: I hate doing progress notes and don’t have the time to do them. Can’t I just create a template with checkboxes, write 2 sentences and be done with it?
Answer: I wouldn’t. Insurance companies, ethical standards and many laws address requirements for contents of progress notes. Sure, checkboxes are easy, but alone, they don’t provide adequate information and under many circumstances, will not meet record-keeping compliance standards. Checkboxes are not descriptive enough to accurately and fully reflect the services provided, as they are one-dimensional. Progress notes must be individualized to the specific client. For example, it is not enough to check off “sad,” because this doesn’t truly capture what “sad” looks like in a particular client.
In order to increase the likelihood of passing the progress notes portion of an insurance audit and to meet state and federal documentation expectations, if using checkboxes, clinicians should always provide narrative data as support. One way this can be done is by documenting the clinician’s observations of the client (The client was tearful throughout the session) and the client’s self-report (“I feel sad, unmotivated and don’t want to spend time with family or friends”). These examples back up the clinician’s declaration that the client’s affect appeared “sad.” Similarly, it is not enough to check off a list of generic therapeutic interventions utilized during the session. Again, it is prudent to provide specific details and examples to illustrate what particular interventions were used, the rationale for choosing the interventions, how they were delivered, what they entailed and how the client responded to them.
According to Optum, among other information, progress notes should include “a clear and detailed description” of what occurred during the encounter and how the client’s presenting problem, symptoms and goals are being addressed. This “detailed summary of the session,” should also include goal-oriented, “descriptive documentation of therapeutic interventions,” (pg. 8) https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/mcs/opMCS.pdf
Question: But, Leslie, seriously, what’s the risk?
Answer: Insurance clawbacks and potential sanctions from your licensing body.
Question: Are they really going to take back money?
Answer: Yes. Insurance companies will either not pay you, your client, or will recoup monies owed to you from future payments.
But I’m an out-of-network provider and my consents inform clients that I refuse to interface with insurance companies. By now, most of you have probably heard, if not experienced, insurance companies (ahem, Optum) have ramped up on conducting pre-payment audits. And not just for in-network clinicians, but out of network clinicians are receiving these notices in droves as well. So, being an out of network clinician does not grant you immunity from having to deal with this headache. If you courtesy bill for clients or provide superbills, you cannot refuse to respond to these requests, unless your clients refuse to allow their records released.
Question: My notes aren’t great. What can I do?
Answer: Progress notes are integral to our work as mental health professionals; they should provide evidence of the services provided, demonstrate medical necessity, inform treatment planning, evaluate effectiveness of the treatment and record progress. Learn what information is needed. Perhaps with more confidence, you will not dread writing progress notes in the future.
This document is for general informational purposes only and is not intended to be used as advice (legal, ethical or technical) or as a substitute for the guidance of an attorney or an individualized consultation. It does not address all possible clinical, legal and ethical issues that may arise, nor does it take into consideration the particular circumstances, nuances or concerns of the situation or person(s) involved. Leslie S. Tsukroff, Inc. does not assume any responsibility or liability for any errors or omissions in its content.
© Leslie S. Tsukroff, Inc. 2024 (All Rights Reserved)
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