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Progress Notes (for TBS and Behavior Coaching)
Transcript of Progress Notes (for TBS and Behavior Coaching)
For TBS Behavior Specialists & Behavior Coaches
Informs our treatment (by sharing info it helps to expedite change and obtain goals faster)
Honors our client’s stories.
Allows the provider to document services and interventions used to reduce impairments (continuity of care)
Documents client’s response/progress to treatment (tracing)
Provides a basis for self-reflection and self-supervision
Risk management liability
Quality assurance and utilization for review
Facilitation of coordination & collaboration of services
Legal and ethical obligation to document all services provided
Documentation generates revenue and allows services to continue
Documentation is the invoice for service provided
Audits are completed regularly by the State and can lead to disallowed services and return of funds
Documentation is how efficiencies are assessed
Purpose of Documentation
There must be a brief written description in the client record each time services are provided
Services to Document
• Appointments w/ clients and caregivers (includes phone/email)
• Checking in w/ treatment team (case managers, therapists, teachers, etc)- (formal and informal)
• Gathering client information
• Developing interventions that will be given directly to client
• Dashboards (updating and analyzing progress to dictate interventions)
• Writing TBS documents (assessment/behavior plan/quarterly and closing)
• Progress Notes (Don’t forget to write the non-billable notes)
• Supervision (time you and supervisor brainstormed interventions for specific client)
• Phone attempts and leaving voice mails (lump all attempts in one day into one note)
Note Section in Handbook
Note Codes Chart
Note examples in the Q Drive
Target Behaviors and Behavior Interventions Charts
An electronic health record (EHR) is a digital version of a patient’s paper chart.
• Providing accurate, up-to-date, and complete information about patients
• Quick access to patient records for more coordinated, efficient care
• Helping providers more effectively diagnose patients, reduce medical errors, and provide safer care
• Enhancing privacy and security of patient data
• Helping providers improve productivity and work-life balance
• Enabling providers to improve efficiency and meet their business goals
• Reducing costs through decreased paperwork, improved safety, reduced duplication of testing, and improved health.
Progress Note Details
: Enter the program the client is in
If client is in more than one program, enter the program that you were working in when you saw them
DATE OF SERVICE
: Record the date the service was provided
Select language provider provided
: Your name should automatically populate
: Should be your assigned clinical supervisor
: Record where the service took place
Always use the client’s location if you’re not in the same place as client
TYPE OF SERVICE
: Record the type of service by selecting code. Refer to Codes below
: Select appropriate service strategy for the service you provided
Refer to Service Strategy PDF link under the header for service strategy descriptions
FACE TO FACE TIME
: (In Minutes): Amount of time the client and staff member are face to face (does not include phone contact, email and texting with client)
OTHER SERVICE TIME
: (In Minutes): Amount of time providing a service when the client is not present
Do not include travel and documentation time
TOTAL SERVICE DURATION
: (In Minutes): Record the amount of time spent for this service. Include time spent face to face, travel, providing other service, and documentation of the service
Give actual time to the minute; do not uniformly record 5-10-15 minute time periods
DESCRIPTION OF ADDITIONAL TIME
: Select boxes that reflect the additional service time accounted for in “Total Service Duration” Field
: Should be your position of which you were assigned to work with client as
To ensure compliance and the completeness of documentation, progress notes must be completed in a timely manner
1. Staff are required to
/Forward for Billing/ Route for approval progress notes within
of when the service was provided. If this is not possible due to scheduling, notes must be “submitted” no later than 3 days.
A comment is required in the comment box of the note if the note is submitted past the 3 day flag.
Situations that are acceptable in turning notes past the 3 day flag (grace period) are: portal is not working, out sick, accident, agency closure day.
Time management and scheduling is not a justifiable reason.
2. Any “rejected” progress notes that requires correction must be “resubmitted” within 24 hours.
3. All progress notes must be “approved” by Supervisor within 7 days of the original service date
Reimbursable vs Non-Reimbursable Services
All staff must understand how services are billed and know that some services are not billable.
Work related to treatment goals, tbs goals, or informing the assessment
related to treatment goals, tbs goals, or informing the assessment
Assisting the client with his homework and taught him a multiplication trick as he has difficulties with math
Sitting with the client in class to help reduce the client’s anxiety by offering them time reminders and prompts to ask for support when becoming anxious
Went to the park and told the client to introduce himself to the kids
Encouraged youth to reduce isolation by prompting client to engage with peers by meeting in the community
Supported youth in using exercise as a coping skill for depressive symptoms
Took youth to the gym and gave suggestions on what exercises he should do
Played a game of dominoes with the client and planed to do it again next session
Assessed youth's ability to stay on task and follow directions
Scheduled appointment with client as there has been recent cancellations
Discussed with youth the importance of weekly meetings as a support for symptom management
Think: Treatment and Clinical Purpose of the activity, the activity is secondary (if it isn't clinical in its nature)
Clear Concise Clinical
Behavior Interventions Response Plan
were you doing? Purpose of session (relate to goal)
were you? Location?
Writer met with client and mother in the home to provide support towards goal #3 (following directions).
___Does the progress note clearly state the purpose of the meeting?
Describe client’s behaviors: Include writer’s observations, client’s self-report, and report from others
Subjective data - client’s observations, thoughts, direct quotes
Objective data about the client-what writer observed (affect, mood appearance)-Use “as evidenced by”
Behavior as it relates to client’s primary focus of treatment (needs, symptoms/behaviors, goals)
Information supports medical necessity and need for service
Include a behavioral report (obtained from an adult) whenever possible. Document attempts/plan to attain report.
Document frequency and duration of target behaviors during session (Indicate if client didn’t engage in target behavior during session
B- Client presented as irritable as noted by lack of eye contact, minimal conversation and agitated tone of voice.
Client’s mother reported that client’s engagement in target behavior, yelling and refusal to follow directions have
remained the same (6x per day). Writer observed client refusing (2x) to follow mother’s request to complete his evening routine expectations.
B-Client presented as irritable as noted by lack of eye contact, minimal conversation and agitated tone of voice.
Client’s mother reported that over the past 3 days, client has engaged in 5 incidences per day in the mild form of the target behavior by refusing to follow directions, and 2 incidences per day of the moderate form by making verbal threats in response to limits and 1 incidence of the severe form by hitting in response to limits. During today’s session client didn’t engage in moderate and severe behaviors, however didn’t follow directions 2 times.
• Consistent with treatment plan- relate/refer to mental health need and to an objective/treatment goal in the client plan
• Focus on Skill-Building (taught, modeled, practiced)- identify specific coping skills used and taught to cope, adapt, respond or problem solve
• Follow up from previous session
• Reinforce new behaviors
• Give justification/context as needed (“Reviewed…when client…” or “Discussed…in order to…”)
• Use time lapse wording to capture and summarize multiple interventions in one sentence (“Throughout the session, writer used…”, “Writer spent time” and “Writer taught the use of deep breathing, walking outside to take space, and listening to loud music…”
•Document interventions that are more proactive not just reactive interventions
I-Writer encouraged client to identify possible triggers to anger and brainstormed alternative responses to reduce anger (i.e. deep breathing, taking space, and counting).
-Writer reviewed with client positive social skills he displayed while playing with peers (disengaging from conflict)
R- Today client was open to participating in skill building around appropriate ways to talk to his mom. Client continues to make progress in meeting treatment goals by being receptive to feedback, skill building, and exploring feeling identification and using deep breathing. Client’s mom was able to give client space and offer options to give client an opportunity to self-regulate.
• Behaviors/goals/ interventions writer will focus on during the next contact
• Plan moving forward to help client reach goals
• Write what the team will continue focusing on
• Indicate next date of service
• High risk notification
• Document plans to follow up regarding risk factors
P- Writer will continue to develop interventions for client to use in practicing coping skills
Describe your specific, individualized interventions or decisions aimed towards treatment goals. If you taught a coping skill or a recovery tool, monitored progress or developed a plan, describe what you did here.
• Be specific (not narrative) in describing client’s behaviors/statements in regards to treatment and interventions
• Document progress/lack of progress over the course of treatment not just from the session
• May include caregiver’s level of engagement, response to interventions and skill development
Describe how the client/family responded to your interventions. Describe client's progress toward his/her goals
Describe what is going to happen next
The intervention you did
A brief description of how you did the intervention.
The purpose of why you needed to do the intervention.
Writer prompted self- monitoring
by using number scale
to increase self-awareness
Writer provided feedback
by stating my observations of interactions with peers
to reinforce positive social skills
Writer modeled and prompted positive communication
by assertively and politely asking for space
when he was becoming withdrawn when sibling was provoking him
Need to know about coding
Pay attention to if your client switches programs, is Katie A eligible, in psychiatric hospitalization or juvenile hall as it will indicate specific note codes
Service code must match service provided
Staff interventions should link back to mental health need and to an objective/treatment goal in the client plan
Note content should show that you provided the service indicated
Attending a client related meeting does not necessarily equate to providing a service
Your note has to indicate your contribution of a service (not just as an observer or what the team did)
Preparations and doing research without the client (although client-related) is not a billable service- so do as much of those activities with the client
Service provided must be within the staffs scope of practice
Service must be authorized
Grouping like with like: Separate billable versus non-billable when lumping in one note
BIRP format is only needed for sessions in which you do interventions with youth and caregiver, and other professionals
communication & coordination that will improve level of functioning
Is face-to-face time accurately billed?
Does the content of the note justify the amount of time billed? (Service activity is proportional to the amount of time billed.)
Is travel time accurately billed? (If travel time is excessive, it should be noted as to why, e.g., traffic accident.)
Is documentation time accurately billed? (15 minutes of documentation time for a two-line note is not an accurate reflection of time and would be questioned in an audit.)
If more than one staff is present from the same Reporting Unit, is the time allocated appropriately?
Divide time between notes for work with multi-youth families
How do you know if your client is in the assessment phase?
Talk to your treatment team
Goals should be in the goal box in the note screen
Make sure to include specific observations and information attained and how that
will inform your work
When a client is in JSC and/or hospitalized (5150’d) you cannot bill for services because it would be double billing. (code to Direct Client Care-Lockout). For Lockout situations, the location of service should always be the lockout location (e.g., jail, hospital, Redwood House, etc.)
To Calculate:TOTAL SERVICE DURATION
BILLABLE TRAVEL TIME
ONLY include travel minutes that are billable to Medical, which are:
-Edgewood office to/from any CLIENT LOCATION
-Any Client Location to another Client Location
NON-BILLABLE TRAVEL TIME
-Alternate Location, etc.
Determining Travel Time
Make Sure to select the appropriate category of DCC:
55-Direct Client Care-Administrative
55-Direct Client Care-IEP
55-Direct Client Care-Lock Out
55-Direct Client Care-Missed Appointment
55-Direct Client Care-Phone Call
55-Direct Client Care-Other
55-Direct Client Care-Lapsed Authorization
Can't be from the same reporting unit
______Is the progress note activity aligned with the client’s plan of care? Are the goals/objectives/interventions reflected in the content of the progress note?
______Would someone not familiar with the note be able to read the note and understand exactly what has occurred in treatment?
______Does the progress note reflect client strengths?
______Is the note written in strength-based language?
______Does the progress note only used approved acronyms? Acronyms can be used if they’re defined first.
______Are professionals identified with full name, title and role in client’s care?
______No other client names should be included in the progress note. Consider confidentiality when using family names as well. Refer to family members by their role only.
______Is note organized (i.e., correct spelling, grammar and punctuation)?
______Is note professional (i.e., objective, factual)?
_______Are sources for information shared documented? (What was said and the context within which it was said; who said it and whether information was given in confidence.)
_______Are facts verifiable and true?
_______Is the note a stand alone document?
Know your clients goals on the treatment plan (ie. Goal 1: Jack will be able to identify 3 coping skills) and document progress in meeting the goals –Is Jack struggling to identify one? Can he identify them but struggles practicing them? Can he identify all 3 coping skills and is using them with minimal to no prompting?
Were they able to disengage this day when prompted when in the past they expressed difficulty doing? Did you notice their increase in setting, clear limits reduced Jack’s defiance?
______Signatures/Electronic entries require printed name, discipline/license, title, and date
______Are credentials and titles updated?
______All documents that require a co-signature by a supervisor are co-signed. Is the proper
Engaged a client in a discussion around appropriate assertive communication in order to decrease arguments with sibling
Explored with client reasons why he is refusing to attend school in order to identify solutions
Reimbursable? Both can or cannot be, Depends on if it is related to the treatment goal!
NOT REIMBURSABLE REIMBURSABLE
Created and Presented by
Strategies for Completing Notes
• Seek supervisor support (identify what the challenge is and brainstorm solutions). Is it time management? codes? distractions in the office? caseload? note content challenging and intimidating?)
•Put note writing time in your outlook calendar- it is a
•Daily note writing time
•Delegate Wednesday and Friday as note days (ensures notes of the week is turned in within 2 days)
•Ideally write within 24 hours, just in case something comes up, you have a 3 day grace period
• Notes at home (if it limits distractions)
• Use time management/note checklist tracking log (ensures that notes aren’t forgotten)
• Set time aside and honor it
• Reschedule or shorten sessions with clients if behind on notes
Find a system that works for you!!!
Expect a learning curve: notes will get rejected and support is available