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Here are the essential characteristics of progress note documentation:
- Presence of Note. For any claim or encounter submitted for these services, a note must be present to justify that specific intervention. In addition, other ancillary or non-billable services related to the well-being of the individual served must be included in the official medical record.
- Service Billed. All progress notes must have the equivalent HIPAA code along with any designated modifier. When documenting these practitioner modifiers, the modifier must specify the reimbursement level which may be different from the practitioner level in some cases. For instance, if an RN provides CSI, then the RN must include the modifier U4 to specify the practitioner level even though an RN is typically a level 2 practitioner.
- Timelines. Any services and activities provided will be documented (written and filed) in the individual’s current record within a pre-established timeframe which is set by the provider policy. It must not exceed 7 calendar days. Best practice standards necessitate that progress notes should be written within 24 hours of the clinical or therapeutic activity. Notes that are entered retroactively (after an event or a shift) into the individual’s record must be labeled as a “late entry”.
- Legibility. All handwritten documentation must be readable, decipherable, and easily discernible for all the readers.
- Conciseness and Clarity. Clear language, grammar, syntax, and sentence structure must be used to describe the activity and related information. Progress Note Documentation must meet DBHDD standards.