MSDP STANDARDIZED DOCUMENTATION TRAINING MANUAL Section 4 Using the MSDP Progress Note Group Documentation Processes/Forms This section provides a sample of each Progress Note form type, guidelines for the use of each form, and instructions for completion of the forms, including definitions for each data field. 129 MSDP STANDARDIZED DOCUMENTATION TRAINING MANUAL Table of Contents FORM NAME PAGE Consultation-Collateral Contact Progress Note 131 Group Psychotherapy Progress Note 133 Health Care Provider Medication Orders Progress Note 137 Intensive Services Progress Note ...
NYSCRI STANDARDIZED DOCUMENTATION TRAINING MANUAL Section 4 Using the NYSCRI Progress Note Documentation Processes/Forms This section provides a sample of each Progress Note form type, guidelines for the use of each form, and instructions for completion of the forms, including definitions for each data field. 339 NYSCRI STANDARDIZED DOCUMENTATION TRAINING MANUAL Table of Contents FORM NAME PAGE Pre-Admission Note 341 Screening/Admission Note 343 Admission Note 348 Contact Note 352 Coordination of Care Progress Note 356 Individual Counseling / Psychotherapy Progress ...
Progress Notes and Psychotherapy Notes This Appendix covers two kinds of notes written about psychotherapy—progress notes and psychotherapy notes—and highlights the practical value of this important distinction. Progress notes are part of the client record or file, as noted below. Psychotherapy notes are not part of the file. After an overview of the client file or record, the difference between these two kinds of notes is discussed along with guides for writing progress notes. The Client File or ...
Progress Note Exercise: Objectives: 1. Participants will be able to understand how to document the link between the Medical Necessity Primary Diagnosis, the Client Plan Objectives, and Interventions in a progress note. 2. Participants will be able to successfully write a progress note which meets Medi-Cal documentation standards linking the Medical Necessity/Primary Diagnosis, Client Plan Objectives, and Interventions. • 30 minutes o Break out in to smaller groups o Each group will collectively identify 2 mental health objectives based upon ...
Psychotherapy Progress Note Use this note to document individual, family or couples psychotherapy sessions and person’s response to the intervention during a specific contact. Data Field Person’s Name Record the first name, last name, and middle initial of the person. Order of name is at agency discretion. Record Number Record your agency’s established identification number for the person. Person’s DOB Record the person’s date of birth. Organization Name: Record the organization for whom you are ...
This sample psychotherapy note was created in 3 minutes using the ICANotes Behavioral Health EHR. The only words typed by the clinician are highlighted in yellow. Visit http://www.ICANotes.com for a free trial or demo. BEHAVIORAL HEALTH OUTPATIENT CLINIC 2121 Main Street Anywhere, USA Date of Exam: 6/9/2016 Time of Exam: 3:38:08 PM Patient Name: Little, Aimee Patient Number: 1000010659748 Psychotherapy Progress Note Mrs. Little seems to have had an inadequate response to treatment as yet. Symptoms of depression ...
Evaluation and Management Progress Note—Based on the Elements Client Name:_______________________________ PSP#:___________ Date:__________________ EM Code:________________ Face-to-Face EM Time:_______________ Total Time:_____________ EM Code Psychotherapy Add-on:_____________ Face-to-Face Therapy Time:__________________ EM Code Interactivity Complexity Add-on (only with Psychotherapy add-on):___________________ Two of three criteria for: (I-III) History, Exam and/or Medical Decision Making must be met. Score the key. 1. HISTORY: Hx of Present Illness (HPI): Past Medical, Family & Social Hx (PFSH), and Review of Systems (ROS) Three must be completed: HPI or ...
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