R03-604 Progress Notes

A. A licensee shall ensure that a progress note is documented in chronological order by date and time and includes the following information, if applicable:

1. A description of each service provided to include:

a. Missed appointments,

b. The amount of time spent providing each service, and

c. Service delivery outcome,

2. Progress made towards treatment plan goals,

3. The client’s response to treatment, and

4. Discharge planning.

Review client file and verify notes are in chronological order.

 

B. A licensee shall ensure that a progress note is dated and signed, either by electronic or handwritten signature, by the individual making the entry.