Progress Note

Every therapy session requires a signed and completed note in the EHR to document the service that was provided. Like in any treatment setting, documenting care at Rula is not only required in order to bill for the encounter, but also to adhere to your ethical, legal, and professional responsibility as a licensed therapist to maintain accurate and timely client records.

Documenting Treatment

At Rula, you have the opportunity to choose from a Progress Note template or a SOAP note template to document treatment. Regardless of which template you select, there are five key quality elements of a note that are often looked for by payers and during care review, so be sure to include these when documenting a service.

• Medical Necessity: What is the clinical rationale for the client to be engaging in the service you're providing? Specifically, your documentation should always clearly reflect your client’s DSM diagnosis, specific symptoms, and associated functional impairments that justify needing the service.
• Clinical Interventions Used:  What are the interventions that demonstrate a clinical skill set was needed to address the client's presenting problem? Beyond core approaches like “listening” and “supporting” , you must identify the clinical skills, approaches, and techniques being utilized in session that are unique to you as a licensed behavioral health provider.
• Client Response: What was the client’s response to the interventions used in session? In your documentation, be sure to describe how your client responded to the clinical interventions that you provided during the session. This helps demonstrate an engaging, collaborative and responsive approach to care.
• Client progress toward treatment goal(s) How does what occurred in session connect back to the current treatment goals and objectives? Including brief notation of whether the client is making progress, is regressing, or no change is observed, is an important element of your clinical assessment each session.
• Plan: What will the client do between this session and the next to promote recovery and make progress towards their goals? It is important to help clients understand that a lot of meaningful clinical work happens outside of your time with them in session. When clinically applicable, it's also helpful to document the client’s plan to utilize their safety plan or  access crisis support (988 - The National Crisis and Suicide LIfeline), should symptoms increase.

Selecting the correct Service Code

In addition to writing the note, it is imperative you select the correct CPT code within the note template to bill the service appropriately. Below are the CPT codes you are able to bill for at Rula:

As a reminder, Insurance companies only cover one psychotherapy session per client per day. Do not bill multiple sessions on the same day.

Progress Note FAQ

• How long do I have to complete notes? All notes should be signed and submitted within 48 hours of the session. 
• Can I bill for the time spent writing session notes? No, the session duration (i.e  session start and end time that you enter in the note and bill for) is only inclusive of the time spent providing services face-to-face with the client, and does not include the time spent documenting after the session.
• How much clinical detail should I include in my notes? To protect client confidentiality, keep notes limited to required elements with basic themes and interventions. You may (but are not required to) keep psychotherapy notes outside of the official medical record to capture more in depth clinical detail that may not belong in a formal 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 all can see the notes I write? 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 them out loud in court or a client was reading their notes from their kitchen.
• Can I see examples of completed notes? We got you! Rula has a Sample Clinical Documentation Library that offers examples of completed notes organized by note type, and that reflect treatment of a variety of client populations, presenting problems/diagnosis and therapeutic approaches. Check them out and even download for reference offline later. 

For technical support on how to navigate a Progress Note template in AMD, check out this brief video

If you have questions or support needs related to Progress/SOAP notes,  reach out to our clinical quality team at quality@rula.com. Therapist to therapist - we’re here for you!