Accurate and comprehensive documentation is a cornerstone of effective mental health care, especially in a telehealth setting. Proper documentation advocates for continued access to care, supports ethical and legal compliance, ensures effective communication among providers, and contributes to improved patient outcomes. When documenting progress notes, therapists should balance including necessary data about client progress, while protecting client confidentiality.
Rula aims to format note templates in a way that encourages clear documentation of all required elements. This article outlines best practices for crafting high quality Progress Notes that meet industry and insurance standards. The examples for each section aim to support sample documentation for a patient being treated for Generalized Anxiety Disorder.
Examples with Rationale and Best Practice Recommendations
Measurement-Informed Care (MIC)
What to Document:
- Select “Yes” to indicate that you reviewed the most recent MIC data.
- Make a selection(s) under “Based on the clinical measures” to indicate how you used the MIC data to inform treatment.
- For any case involving imminent danger to self/others, a C-SSRS score 2>, and/or PHQ-9 score above 19, a safety plan is required to be present in the chart and the client should be offered crisis resources, like the Rula crisis hotline.
Rationale: Clinical assessments provide objective data to track symptoms over time, ensuring treatment effectiveness and improving clinical decision-making. They also support value-based care models. To learn more about MIC, its effectiveness, and how to utilize it with clients, please visit this article.
Example:
Symptoms
Current Symptoms:
What to Document: Symptoms that the client is currently experiencing or has recently experienced between now and the last session.
Rationale: Documentation of current symptoms is helpful in tracking progress in treatment. Continued presence of symptoms also supports the case for medical necessity of continued care.
Example:
Symptoms: “Feeling nervous, anxious or on edge; Difficulty relaxing; Irritability; Uncontrollable worry; Anxiety attacks,” (F41.1 Generalized Anxiety Disorder).
Areas of functional impairment/ How are symptoms specifically impacting clients functioning in this area?:
What to Document: How each symptom is resulting in difficulty fulfilling roles in key life domains or a negative quality of life for the client
Rationale: Documentation of functional impairment is vital to prove a case of the medical necessity of care. If one is finding there is little or no impairment, this can be a sign to consider termination, especially because insurance will not cover ongoing sessions without medical necessity.
Example: “Social/relational”- “The client’s experience of uncontrollable worry, feeling on edge, and irritability are negatively impacting his relationship with his partner, resulting in increased fighting and discord in the relationship. This conflict impacts his mood and ability to function at work. Additionally, this client experiences worry and racing thoughts in social relationships, resulting in him having “no friends” and experiencing loneliness due to social isolation.”
Focus of session/ session summary:
What to Document: The key points discussed during a therapy session, including the client's presenting concerns, interventions used by the therapist, client interaction and participation, and how this session demonstrated progress (or lack thereof) toward treatment goals.
Rationale: This is necessary as a record of what occurred during the session and how therapy is assisting the client in meeting their treatment goals. Even if this information is present in other parts of the note, insurers request the inclusion of a comprehensive summary section.
Best practices:
- Be succinct- this section does not need extensive detail to meet requirements.
- Keep client privacy in mind. Often, things like partner names or very intimate details are not necessary to include in a progress note unless it is clinically necessary to convey medical necessity.
- Utilize professional, objective, patient-centered language.
Example: “Client rated anxiety levels over the past week in different situations on a scale from 1-10. Client described instances of progress in which he was able to utilize box breathing/grounding for nervous system re-regulation and cognitive defusion to assist with worry thoughts. However, he noted ongoing difficulty with utilizing assertiveness techniques to address conflict with his partner. The session was spent learning additional CBT strategies, practicing assertive communication techniques, and developing a plan for how to use new skills this week.
Treatment
Treatment approaches used in session/ specific interventions used in the session:
What to Document: Specific evidenced-based modalities and interventions used during the session. These can be selected from the drop-down list in the Rula portal and/or therapists can write in free text to describe specific interventions.
Rationale: It is important to demonstrate the targeted clinical interventions used by the therapist to treat the presenting problem and work toward treatment goals. For ethical and compliance reasons, only evidenced-based modalities and interventions can be used at Rula.
Example: CBT; “Explored how the client dealt with difficult situation in the past; Had client identify how he would deal with feelings with facing the same problem again; Helped client identify dysfunctional coping mechanisms; Processed fears; Offered cognitive reframing of thoughts
Client Response to Interventions:
What to Document: Detail how the client responded to the specific interventions used in the session (as noted in the Interventions section). It can also include how the interventions led to progress toward meeting treatment goals. Avoid generalizations like “open”, “receptive”, or “engaged.” If using these terms, include “as evidenced by…” and detail your assessment of how the client responded.
Rationale: This can be an effective way to track what is or is not helpful to the client, resulting in actionable changes, and leading to progress in therapy.
Example: Client endorsed frustration with his ongoing anxiety and relationship patterns but stated that he “had a lightbulb moment today” during cognitive reframing activity when he was able to reconceptualize situations that cause frustration as learning opportunities. Client reported that this insight was helpful to increase his motivation to change and to try out new behaviors to manage anxiety and relationship conflict, whereas previously he was too frightened out of fear and the unknown.
Diagnosis
Diagnosis:
What to Document: Clinically appropriate diagnosis(es)
Rationale: A diagnosis helps determine the best treatment options for the client and informs the insurance partner of the specific condition being treated with therapy. At least one F-code is required to bill for services.
Best practices:
- Within each progress note, refer to DSM-5 for diagnostic criteria, and speak to the diagnostic criteria throughout your documentation (E.g. in the specified sections for Symptoms, Functional Impairment, Session Summary, and Plan).
- Support the assigned diagnosis(es) throughout the note with evidence of reported symptoms, MIC data, and observed behaviors.
- Including an improvement in symptoms that the client previously experienced is another way to support a billing diagnosis. For example, for a client with bipolar disorder, you may include that the client denied experiencing any recent manic symptoms.
- Periodically review diagnoses for their ongoing accuracy and relevance to the client’s current situation. If a diagnosis is no longer applicable due to progress or changes in symptoms, document the rationale for its removal and communicate this with the client.
- For other best practices regarding diagnoses, please check out this article.
Example: “F41.1, Generalized Anxiety Disorder”
Length of Treatment, Session Frequency & Session start/end time:
What to document: You can only bill for time actively spent with the client, not time spent waiting for the client or documenting the session. You may only bill for the entirety of the clinical hour (e.g. 11-12pm) unless 53+ minutes were spent with the client. In other words, only the time spent with the client influences the CPT code billed.
Rationale: Documentation of time spent with the client and the associated CPT code needs to be accurate. A pattern of sessions that starts and ends at the :00 or :30 is often flagged by auditors.
Plan/Homework for next session:
What to Document: The Plan/Homework section should specify what the client will do between sessions to make progress toward treatment goals, such as specific homework, skills practice, and/or use of their safety plan if applicable. Additionally, your note should also specify the frequency of visits, length of time between visits, and next visit date. These should align with the client’s diagnosis(es) and acuity as documented. If you select a frequency of “Other”, include “Comments” to explain why (e.g., Patient is being sent to a different therapist or recommended for a HLOC).
Rationale: This serves as a roadmap for both the therapist and client, ensuring that each session builds upon previous work. Additionally, insurance partners expect to see clear documentation of what the client will do to make progress toward treatment goals between sessions.
Example: “Client will practice assertive communication techniques in one interaction with his partner and journal about the experience.”
Treatment Plan
What to document: Record the client’s goal in their own words (“Client’s Goal”), translate that goal into clinical language (“Clinical Goal”), and measurable actions the client will take to work toward their goal (“Short-Term Objective(s)”). Ensure that treatment goals are in aligned with the billing diagnosis(es).
Best practices:
- Utilize the SMART (Specific, Measurable, Achievable, Realistic, Time-Bound) framework to develop treatment goals. The Short-Term Objective section of the Rula Treatment Plan is where you should specify the measurable steps, behavior shifts, and/or skills that the client needs to make progress toward their goal
- Ensure treatment goals are related to the DSM-5 criteria for the client’s assigned diagnosis(es).
- Consider up to 3 treatment goals. More than 3 can feel overwhelming to a client and potentially dilute the efficacy of treatment.
- In order to meet compliance standards, update the treatment plan at least every 3 months.
Example:
- The client reports their goal is to: “calm my anxieties, I feel like crawling out of my skin”
- The client’s clinical goal is: Skill acquisition; Symptom reduction
- Short-Term Objective: “Practice 15 minutes of guided breathing exercises at least five days per week for the next eight weeks, in order to reduce baseline anxiety levels."
- Why the example goal is SMART:
- Specific: The goal clearly defines the actions (practicing breathing exercises) and the desired outcome (reduction in anxiety level).
- Measurable: Progress is measured by the duration of exercises practiced and the number of days per week.
- Achievable: This activity (daily breathing exercises) are realistic and manageable for most clients.
- Relevant: The goal directly addresses the client’s anxiety, aligning with their diagnosis and desire for symptom improvement.
- Time-bound: The eight-week timeframe provides a clear deadline for achieving the goal.
To learn more about treatment planning, please visit this article. More examples can be found here, as well as a resource that discussed how to use MIC to inform treatment planning.
A final “rule of thumb” to keep in mind when documenting Progress Notes is to consider how the patient would react to reading your clinical notes. After all, clients can and do request their record often, and we want to ensure that they feel honored and respected by their care providers when they read how you wrote about them!
Want to see how all of this fits together to create an effective, compliant note? Rula offers a robust Sample Documentation Library, including examples of many different progress notes for adult, child, couples, and families!