Robert W. Marrs, MS, LMFT

Writing Progress Notes

On Behalf of Wisconsin Association for Marriage and Family Therapy

5/7/2012

Writing Progress Notes

The following slides are presented on behalf of Wisconsin Association for Marriage and

Family Therapy and are intended to provide best practices in writing outpatient

psychotherapy treatment notes. The information presented is based on the HIPAA Privacy Rule and Wisconsin laws and statutes

regulating the practice of psychotherapy.

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Writing Progress Notes

Robert Marrs is a licensed marriage and family therapist and AAMFT approved clinical supervisor. He is past president of Wisconsin Association for Marriage and Family Therapy,

and serves as the Manager of Clinical Services at Aurora Family Service in

Milwaukee, Wisconsin.

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Defining PsychotherapyWisconsin Chapter 457.01 (8m)“Psychotherapy” means the diagnosis and

treatment of mental, emotional, or behavioral disorders, conditions, or addictions through the application of methods derived from established psychological or systemic principles for the purpose of assisting people in modifying their behaviors, cognitions, emotions, and other personal characteristics, which may include the purpose of understanding unconscious processes or intrapersonal, interpersonal, or psychosocial dynamics.

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Defining Marriage & Family Therapy

Wisconsin Chapter 457.01 (5)“Marriage and family therapy” means

applying psychotherapeutic and marital or family systems theories and techniques in the assessment, marital or family diagnosis, prevention, treatment or resolution of a cognitive, affective, behavioral, nervous or mental disorder of an individual, couple or family.

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Common Definitional Elements: Diagnosis & Assessment

Mental, emotional, cognitive, behavioral, systemic disorders

Addictive disorders Mental health conditionsPersonal characteristics

TreatmentApplication of theoriesApplication of techniques

OutcomeResolution or prevention of identified disorders /

conditionsModification of behaviors or personal characteristics

These are the psychotherapeutic activities that should be documented in a session progress

note.

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The “Golden Chain”Everything in the mental health record links together in

what is referred to in healthcare as the “golden chain”. It includes the intake/assessment, the diagnosis, goals/objectives, service plan, DAP progress notes, and discharge plan.

The psychotherapy progress notes are a crucial link in the chain connecting the therapist’s work in treatment with the diagnosis and established treatment goals.

(HIPAA 45 CFR 164) Progress notes document the psychotherapy, or marital and family therapy being provided, and describe the patient’s progress toward identified outcomes.

It is considered best practice to complete and sign your progress notes within 24 hours of the therapy session.

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Definition of a Progress Note Progress notes must include the following:

Session start and stop timesModalities and frequencies of treatment furnishedResults of clinical tests and assessments, andAny summary of the following:

DiagnosisFunctional statusSymptomsPrognosis, andProgress to date

Signed and dated by the treating provider including the providers educational degree and credential

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Definition of a Progress NoteIn other words, your progress notes need to

include:Description of major events or topics discussed (D)Specific interventions provided (D)Observations and assessment of the patient’s status

and functioning (A) Including current Dx, risk status, and GAF score

Any plans for the future including (P):Homework assignedRecommendations

Additional resources Alternative treatments

One of the most common progress note formats is DAP: Data / Assessment / Plan

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What is NOT in a Progress Note?Therapist hypothesesTherapist speculationTherapist personal feelings or judgments about the

patientAny information, events, experiences, or

descriptions not relevant to the patient’s functional status and treatment plan

Identifying information about persons who are not directly involved in the patient’s treatment

Clinical judgments, conclusions, impressions, or diagnoses that cannot be justified by accepted methods of assessment and treatment, therapist scope of practice, and other acceptable forms of clinical evidence.

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Scope of PracticeThe basic intent of scope of practice is to

ensure that a healthcare professional has the appropriate education, knowledge and experience to care for a patient. Scope of Practice is defined by the following:State and Federal LawLicensing / credentialingStandards of care and professional conductEmpirically tested or universally accepted

theories and techniques

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Scope of PracticeConsider the following factors when

determining scope of practice:Patient population (E.g., age, gender, socio-

economic status, culture)Cultural competency matters

Patient diagnosisIdentified patient system (E.g. individual,

couple, family, group)Therapeutic interventions and techniquesMethods of assessment

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Progress Notes (Cont.)Therapists should never write anything in a

progress note that is not reflected in their scope of practice

Therapists should never write anything in a progress note that cannot be justified or validated by appropriate clinical evidence and investigation

Less is better!Exception:

Situations involving increased risk of harm to self or othersDecisions regarding voluntary / involuntary dischargeSignificant changes in functionality and/or level of careAny other critical incident as defined by policies and

procedures

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Progress Notes: Additional TipsConsider how the patient is representedAvoid using words like “good” or “bad” or any other

words that suggest moral judgmentsAvoid using tentative language such as “may” or

“seems”Avoid using absolutes such as “always” and “never”Write legiblyUse language common to the field of mental health

and family therapyUse language that is culturally sensitiveUse correct spelling / grammar – proofread your

notes

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Progress Notes: Additional TipsLook for potential biases that may misrepresent the

patient, or suggest boundary violations in the therapeutic relationship

Provide detailed information regarding any additional services or resources that are recommended for the patient as well as the patient’s response to these recommendations

Provide specific information regarding any additional assessment or test instruments used (E.g. Beck Depression Inventory), including the results of the test, their relationship to the treatment plan, and the patient’s response. Be sure you are qualified to administer such inventories

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Progress Notes: Additional TipsBelow are the different types of progress notes written

during the course of outpatient mental health treatment:

Initial Assessment / Admission Note – Written after the first therapy session in which you conducted a biopsychosocial assessment of the client system. This session should always be coded as “initial assessment (90801).

Individual Session – Written after every therapy session in which the client system was an individual (90806)

Couples/Family Therapy Session – Written after every therapy session in which the client system was a couple or family (90847)

Collateral Session – Written for therapy sessions when members of the client system are present without the client him/herself (90846)

Client Consultation – Written whenever you consult the case with a supervisor/consultant/ or other treatment provider (code it as non-face-to-face time)

Non-Billable – Written for any other event, activity, or communication that is not considered a “billable” service by industry standards.

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Progress Notes–Initial AssessmentAdmission Note – The therapist must write a

progress note following the initial assessment session with the patient. This progress note, or admission note, should also include:Presenting problemWho participated in the sessionTherapist observationsAcknowledgment of informed consent and

patient rights discussionsAcknowledgment that a biopsychosocial

assessment was performedAcknowledge of any risk factorsTherapist recommendations

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Progress Notes-DischargeDischarge Note – The therapist must

write a progress note following termination with the patient. This progress note, or discharge note, may correspond to the final session, or as part of the discharge summary. It should include the following:Summary of treatment providedLevel of progress achieved according to the

current treatment planReason for terminationRecovery plan / recommendations

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Psychotherapy Notes“Psychotherapy notes” means notes recorded (in

any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the patient’s medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. 45 CFR 164.501.

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Psychotherapy NotesThe key elements of psychotherapy notes and its use

are that psychotherapy notes:Are produced by a mental health professionalAre separated from the rest of the medical recordDo not include the basic treatment and record-

keeping that goes in a standard progress note, andAre not open to disclosure to the client or anyone

elseProviders should not keep psychotherapy notes

without the permission of their clinical supervisor and/or clinic administrator. If approved, the provider should maintain his/her psychotherapy notes in accordance with clinic policy and the HIPAA Privacy Rule.

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E.g. Initial Assessment Session (90801)

Data: Client is 35 yr old African American male presenting with his spouse, Tameka (age 30), for couples therapy. Couple reports high conflict, low intimacy, and low satisfaction for approximately 15 months following the death of their second oldest child. Writer discussed couple’s preferred outcome for therapy as well as their marital relationship. Couple agrees to commit to a minimum of 6 sessions. Also discussed informed consent including HIPAA, Confidentiality, and client rights. Writer initiated a biopsychosocial assessment and conducted a risk assessment: client reports occasional binge drinking. No reports of homicide or suicidal ideation at this time.

Assessment: Client’s symptoms include depressed mood, grief, mild anxiety, and bouts of excessive drinking suggesting initial diagnosis of Adjustment Disorder with Mixed Emotions. Rule out diagnosis of substance abuse and dependence. Spouse, Tameka, presents with symptoms of depressed mood, anger, and irritability. Tameka also reports lifelong history of being treated for depression. Client’s current GAF = 53. Tameka’s GAF = 51.

Plan: Writer provided information for support group for parents grieving the loss of child offered at West Allis Memorial Hospital. Writer will coordinate Tameka’s care with her prescribing psychiatrist. Writer also provided information for outpatient medical services because client reports he has not received a physical examination in over 5 years. Writer will provide CAGE assessment for problem drinking at next session, and begin a course of marital therapy. 5/7/2012

E.g. Follow-up / Standard Session (90847)

Data: Couple presents today under duress, reporting that this past week couple had an argument in which Tameka implied that client was somehow culpable for their child’s death. This resulted in client leaving the home and getting drunk. Writer processed event with couple, and coached partners to discuss their grief in a softening tone. Writer then discussed ways to maintain healthy boundaries at home and to limit challenging conversations to therapy sessions for now. Lastly, writer discussed specific treatment goals for couples therapy.

Assessment: Dx 309.28. GAF = 53. Writer provided CAGE assessment. Results indicate pattern of alcohol abuse, but not dependence. Writer also connected with Tameka’s psychiatrist and arranged for an office visit. Dr plans to increase SSRI dosage for a minimum of 9-12 months. No other risks identified at this time.

Plan: Writer will provide education and resource information regarding alcohol abuse, and review marital therapy treatment plan at next visit.

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E.g. Discharge Session (90847)

Data: Couple presents today for their final marital session. Couple reports increased intimacy, decreased conflict, improved communication skills, and high relationship satisfaction. Client reports elimination of binge drinking pattern. Tameka reports better management of depressive disorder. Discussed progress on treatment goals as well as plans and recommendations for aftercare.

Assessment: Dx 309.28. GAF = 63. Couple completed all treatment goals and have made significant improvements in the quality of their relationship. This completes a course of 13 marital therapy sessions. No additional risks have been identified.

Plan: Couple will continue with grief support group at West Allis Hospital, and engage in supportive activities at their local faith community. Couple meets criteria for discharge and will terminate treatment at this time.

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Wisconsin Code of ConductMPSW 20.02 – In the State of Wisconsin, MPSW 20.02 – In the State of Wisconsin,

professional misconduct includes:professional misconduct includes: (18) Failing to maintain adequate records relating to services

provided a client in the course of a professional relationship. Acredential holder providing clinical services to a client shall maintainrecords documenting an assessment, a diagnosis, a treatmentplan, progress notes, and a discharge summary. All clinicalrecords shall be prepared in a timely fashion. Absent exceptionalcircumstances, clinical records shall be prepared not more thanone week following client contact, and a discharge summary shallbe prepared promptly following closure of the client’s case. Clinicalrecords shall be maintained for at least 7 years after the last serviceprovided, unless otherwise provided by federal law.

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Relax…

You are in a training program learning how to do this. We don’t expect your notes to be

perfect, but we do expect that you do them and do them within the required timeframe. The quality of your notes will improve with time. Please know that we are always here

to help you.

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Please consult your clinic’s policies and procedures manual, and the Wisconsin

Department of Health Services Bureau of Quality Assurance for best practices in

mental health documentation

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