Rula Documentation Feedback Email

If you received a Rula Documentation Feedback email, use this guide to learn about the most
common feedback categories and what they mean. 

If any of these areas were flagged in your feedback email, that’s your cue to review and improve that part of your documentation moving forward.

 

Feedback category

What it means

Meets Expectations

Needs Improvement

Timely documentation

 Documentation is completed within 48 hours of the session end time. Entering notes within 48hrs Entering notes after of 48hrs
Measurement informed care*

MIC measures are completed by patient, provider is checking box indicating measures were reviewed, and documentation is in the note regarding how the measures were used to inform treatment.

*For a full description of assessment tools and visuals, visit this help center article.

 "Reviewed PHQ-9 score of 16 with client and explored factors contributing to increased depressive symptoms, including recent family conflict. Adjusted session focus to emphasize ACT diffusion exercises to address negative self-talk driving depressive symptoms. Client noted that the higher PHQ-9 score did not match perceived ability to cope; discussed strategies to monitor and respond to worsening mood." "Measures were used to inform treatment" or "Measures were reviewed and considered"

Medical necessity

The note must have:

  1. Symptoms that support the diagnosis and are current to that week’s reporting.
  2. One of the following is met:
    • The documented symptoms are causing a functional impairment in at least one life domain (e.g. work, school, relationships, ADLs, attention span, task completion, stimulus tolerance, etc.).
    • The client has a history of symptoms that cause a functional impairment in at least one life domain, and without therapy the client is at risk of symptoms returning.
  3. For the question, “How are symptoms specifically impacting the client’s functioning in this area?”, the provider describes how the symptoms affect the client within that domain. For example: “The client experiences panic attacks before meetings with their boss, leading to missed work meetings and negative performance reviews. They report severe worry about potentially losing their job.”

OR

Commentary regarding improved symptoms / getting ready for discharge or step down from treatment would meet medical necessity.

Symptoms: Appetite decreased, excessive sleep, feelings of hopelessness, lack of motivation, little interest or pleasure in activities.


Areas of Functional Impairment: Social/Relational. Activities of Daily Living 


How are symptoms specifically impacting client’s functioning in this area? "Client reports isolating more and “losing friends” due to difficulty leaving the apartment. Client often goes days without showering or brushing teeth due to lack of motivation and feelings of losing interest in daily activities."

Symptoms: anxiety and insomnia 


Areas of Functional Impairment: Social/Relational. 


How are symptoms specifically impacting client’s functioning in this area? The client is doing well and is enjoying their job

Sufficient clinical summary

Intake—Comprehensive recap includes:

  • Symptoms that support diagnosis and functional impairments
  • Pertinent biopsychosocial factors affecting presenting issue
  • Client presentation
  • Not 100% copied from another part of the note

Progress note—Detailed summary of session including:

  • Symptoms/functional impairment
  • Therapeutic intervention addressing symptoms
  • Patient interaction/participation
  • Progress towards goals or lack thereof
 "Session centered on assessing and addressing depressive symptoms contributing to social withdrawal and functional decline. Therapist and client reviewed PHQ-9 results and discussed recent interpersonal stressors, particularly a conflict with a family member that triggered increased feelings of worthlessness. Using ACT-based interventions, therapist guided exploration of negative self-talk patterns maintaining depressive symptoms. Client practiced a cognitive diffusion exercise, identifying unhelpful beliefs.Therapist reinforced the importance of behavioral activation and small daily tasks to counter avoidance. Overall, the session focused on increasing psychological flexibility, enhancing self-awareness of cognitive patterns, and developing coping strategies aligned with client values." "Explored relationship resentment" or "Reviewed client's week and what was difficult for them" or "Revisited last session's topics and dove deeper" or "Therapist asked client clarifying questions. Therapist validated client's feelings. Therapist actively listened as client shared thoughts and feelings."

Clinical interventions

Documentation includes at least 2 selected dropdown intervention options.

OR

There is additional free text documentation of interventions that align with the diagnosis and/or presenting problem.

 "Acceptance & Commitment Therapy (ACT), Supportive Therapy" "Talked"

Client’s response to interventions

Client's unique response to clinical intervention(s) is documented.

  • Client quotes may be used.
  • Client response aligns with interventions used in session.

Does not only say: "Client was receptive to interventions" or something similar.

 "Client actively engaged in diffusion exercise, stating the question “Is holding on to this thought/belief helpful?” was useful. Reported feeling “less stuck” after practice." "Client responds well and is very self aware"

Progress toward treatment goals

 Progress toward treatment goals is documented (dropdown can't be blank or N/A). "Regression since last session" "n/a"

Session time

 Ensure accurate documentation by recording the actual start and end times of the session (i.e., when the client enters and leaves), rather than defaulting to the hour or using the provider's entry/exit times. --------- ---------

Documentation supporting the diagnosis(es)

Intake: Diagnoses are fully supported by DSM 5 criteria.


Follow-up: Notes include symptoms supporting each diagnosis.

dx: F40.10 Social Anxiety Disorder 

sx: Racing thoughts, negative self-talk, dry mouth, difficulty breathing, tremors, frequent crying

dx: F41.1 Generalized Anxiety Disorder


sx: impulsivity, unstable affect, feelings of emptiness, anger, and paranoia

Reviewing treatment plan

 Review treatment plan at least once every 3 months to ensure current accuracy. --------- ---------

Plan and recommendations aligning with the patient’s needs and level of care

Intake: Frequency, length of time, and next visit are filled out and in line with diagnosis.

Follow-up: 

  • Frequency, length of time, and next visit are filled out and in line with diagnosis OR if frequency is “other”, ensure there is support reasoning in the “comments” box (e.g., patient is being sent to another therapist or recommended for inpatient care).
  • Documentation includes what the client will do between sessions to make progress toward treatment goals.
  • Details about homework, skills practice, referrals, and/or use of safety plan (if applicable) are included.
 Plan / Homework: The client will monitor critical self-statements and practice the diffusion exercise over the next week. Review safety plan and crisis resources in case depressive symptoms or hopeless thinking increase. Plan / Homework: The client will come to therapy

Treatment plan goal aligns with the diagnosis

 There is at least one goal that is aligned with the diagnosis and specific to the client—they align with patient's unique functional impairments, diagnosis, and overall clinical presentation. dx: F33.1 Major Depressive Disorder, Recurrent Episode, Moderate
Tx plan goal(s): 1) client will increase engagement in daily self-care by completing at least 3 planned activities per week (e.g., showering, taking a brief walk, preparing a meal), as tracked in a weekly activity log. 2) Within 6 weeks, client will identify and challenge at least 3 negative automatic thoughts per week using a CBT thought record, as demonstrated by completing and reviewing records in session.

dx: F33.1 Major Depressive Disorder, Recurrent Episode, Moderate

Tx plan goals: 1) reduce daily episodes of panic and manage excessive worry. 2) Client will organize their entire home and complete all outstanding household projects within the next month.

Measurable goals

Goals have at least one measurable and specific component: SMART goals

  • Client-stated goal: Describe the client's goal in their own words.
  • Clinical goal: Select from the dropdown (e.g., skill acquisition, symptom reduction, etc.).
  • Short-Term Objectives: Outline the specific behaviors, skills, or steps the client will take to address the presenting problem and move toward the goal. Include frequency and ensure alignment with the diagnosis. For example, for a client with GAD: “The client will learn 3 deep breathing strategies and practice them 3 times per week."
  • Progress Measurement: Identify how progress will be tracked (e.g., self report, reduction in MIC scores, therapist observation, homework completion, parent/guardian report—select from dropdown).
  • Estimated Timeframe: Specify a realistic and clinically appropriate period for achieving the goal (e.g., within the next 12 visits).

Tip: Many providers are sent feedback because their short-term objectives are not specific enough!

The client reports their goal is to: Reduce physical symptoms of anxiety and increase
emotional regulation


The client's clinical goal is: Symptom reduction


Short-term Objective(s): Client will identify and track somatic symptoms of anxiety (e.g.,
numbness, loss of feeling) and related triggers at least 3x/week. Client will use one grounding
technique (such as 5-4-3-2-1 senses, deep breathing, sensory focus) during moments of
heightened anxiety. Client will demonstrate increased ability to challenge catastrophic
thoughts using cognitive restructuring tools.


Progress will be measured by: Reduction in GAD-7 score,Reduction in PHQ-9
score,Completion of homework/assignments,Client self-report


Estimated time to achieve goal: Within the next 3 months or 12 visits

The client reports their goal is to: Focus more
The client's clinical goal is: Symptom reduction


Short-term Objective(s): Client will work to discover new routines and feel better 


Progress will be measured by: Reduction in GAD-7 score,Reduction in PHQ-9 score


Estimated time to achieve goal: Within the next 3 months or 12 visits 
 

Inclusion of cultural considerations (intake)

Cultural considerations describe how the client's cultural or other identities impact their mental health, their perceptions and understanding of their symptoms, or their help seeking behavior and engagement with mental health service providers. 

Some examples of topics to be covered in this section are:

  • Ethnicity, nationality, language(s) spoken, and preferred language for communication.
  • Religious or spiritual beliefs, practices, and their role in daily life.
  • Gender identity, sexual orientation, and how they intersect with cultural identity. 
  • Role of family, community, or cultural groups in decision making and support.
  • Expectations and norms, understanding, and/or stigma regarding mental health within the client's culture.
  • Language barriers, financial constraints, or mistrust of medical systems.
  • Experiences of discrimination or marginalization.
  • Cultural strengths such as resilience, spirituality, or strong community ties.
 Growing up in an environment that valued privacy, emotional restraint, and handling problems independently may contribute to the client’s difficulty expressing needs or reaching out for support. These cultural expectations can reinforce long-standing patterns of keeping emotions contained as a way of coping. The client was raised in a family system where meeting basic needs took priority over emotional connection, and healthy communication around feelings was not modeled. A history of emotional neglect, along with earlier experiences of interpersonal harm, has shaped a strong sense of mistrust and caution in close relationships. These relational patterns are often learned and passed down through family and cultural context, influencing how the client currently navigates safety and vulnerability. Response: n/a or none

Note Individualization

 Each note must include specific details about what occurred in the client's session that day, with unique content in the free text sections (e.g., Functional Impairment, Session Summary, Client Response, Homework & Plan).

Week 1: Session centered on assessing and addressing depressive symptoms contributing to social withdrawal and functional decline. Therapist and client reviewed PHQ-9 results and discussed recent interpersonal stressors, particularly a conflict with a family member that triggered increased feelings of worthlessness. Using ACT-based interventions, therapist guided exploration of negative self-talk patterns maintaining depressive symptoms. Client practiced a cognitive diffusion exercise, identifying unhelpful beliefs.Therapist reinforced the importance of behavioral activation and small daily tasks to counter avoidance. Overall, the session focused on increasing psychological flexibility, enhancing self-awareness of cognitive patterns, and developing coping strategies aligned with client values. 

Week 2: The session focused on evaluating and reducing depressive symptoms that have been driving the client’s increasing isolation and difficulty completing daily tasks. The therapist and client reviewed updated PHQ-9 scores and discussed a recent disagreement with a close friend, which heightened the client’s sense of discouragement and self-blame. Using Acceptance and Commitment Therapy strategies, the therapist supported the client in noticing and labeling internal narratives fueling their depressive mood. The client engaged in a cognitive defusion activity by observing negative thoughts as passing events rather than facts, identifying several beliefs that frequently contribute to avoidance. The therapist emphasized the importance of re-engaging in small, manageable actions to interrupt inactivity and build momentum. The session centered on strengthening psychological flexibility, improving awareness of internal experiences, and developing value-aligned coping tools to support mood stabilization and daily functioning.

Week 1: Client met for individual therapy. Client processed her upcoming move and the stress that comes with getting everything ready for the move. Client reported feeling distanced from family members. Therapist processed feelings with the client and provided psychoeducation around anxiety triggers and discussed use of anxiety journal to record anxious thoughts. Client reported her anxiety is a 6/10 today. 

Week 2: Client met for individual therapy. Client processed her upcoming move and the stress and nervousness that comes with getting everything ready for the move. Client reported still feeling distanced from family members. Therapist processed feelings with the client and provided more psychoeducation around anxiety triggers and discussed use of anxiety journal to record anxious thoughts. Client reported her anxiety is a 5/10 today.

 

Updated

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