As is the standard industry practice, therapists seeing clients through the Rula network must complete the required documentation for all therapy services rendered. Our provider portal contains ready-to-select “templates” for each note type to support you in completing required documentation in a thorough and efficient way.
Documentation Requirements for Therapy Clients
- An Initial Assessment (90791) Note template for the first visit. Per commercial payer requirements, you must use the Initial Assessment note template for this service. Use of a progress note template or blank note template for the initial assessment, will not be accepted. This service can be billed for up to 90 minutes.
- A Treatment Plan that is created at the onset of care, and updated as clinically indicated throughout treatment. Clinically indicated may mean:
- When a client meets their previous treatment objectives/goals and establishes new ones
- When a client is not making clinical progress on the current treatment plan and a collaborative decision is made to modify the plan, objectives, and/or approach to care
- When a client is presenting with increased risk and session focus needs specifically to target the resolution of the current crisis state.
- Any time there is a change in the diagnosis, a diagnosis is removed, or a new diagnosis is added.
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Progress notes (or SOAP notes, if you prefer) for each subsequent session. The code used for the note will vary, depending on the length of the service and who was present. As a reminder, you can only bill for the time spent face-to-face with the client(s), and cannot bill for time spent documenting or other clinical activities pre/post session.
- Please be aware that all progress notes must contain information related to the medical necessity of therapy for your client.
- A Discharge Note to document when an episode of care has concluded. Note: a discharge note is non-billable, but still an important component of care documentation. If a discharge note is documenting the final session of care, then a progress note also needs to be completed in order to bill for the service.
While not required for every client, the below documents should also be completed when clinically indicated:
- Safety Plan
- Risk Assessment
- Missed Appointment note
- Blank note to capture important information related to outreach, care coordination, or other clinical information that should be reflected in the medical record.
Clinical Documentation FAQ:
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What do I need to show in my documentation? It’s important to demonstrate the following:
- A DSM-5-TR diagnosis
- The presence of associated symptoms
- Functional impairments
- Targeted interventions that address functional impairments
- A treatment plan with specific, measurable goals
- Progress in treatment and symptom severity
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How much clinical detail should I include in my notes? To protect client confidentiality and to preserve the therapeutic relationship, keep notes limited to required elements with basic themes and interventions. These typically involve:
- A brief description of the focus of the session
- Specific symptoms and how the symptoms are impacting the client (functional impairment)
- Clinical interventions used in the session
- Client’s response to your interventions
- Client’s progress toward treatment goal(s)
- Plan - what the client will do in between sessions to make progress towards goal(s)
You may (but are not required to) keep psychotherapy notes outside of the official medical record. HIPAA gives added protection to “psychotherapy notes.” A helpful article on the topic is available here.
Interested in reading further about what to leave in, and what to leave out in your notes? Check out this blog post!
- Who can see the documentation I complete? All notes entered into the EHR are part of the client’s medical record, and as such, they are discoverable and accessible to the client or parent/guardian (in accordance with HIPAA) and may be shared with the payor or an external party upon the client’s written consent. It is helpful to keep this in mind when writing your notes. A good piece of advice is to write your notes as if a judge were reading your notes out loud in court or a client was reading their notes from their kitchen.
- Where can I find examples of completed documentation? We got you! Rula has a Sample Clinical Documentation Library that offers examples of completed notes organized by note type. The notes reflect treatment of a variety of client populations, presenting problems/diagnoses, and therapeutic approaches. Check them out and even download them for reference offline later.
Additional Support
If you would like additional support related to completing the required documentation at Rula, check out options for connecting with the Clinical Quality team here or email them directly at quality@rula.com. Therapist to therapist - we’re here for you!