Common use of PROGRESS NOTES Clause in Contracts

PROGRESS NOTES. a. Contractor shall create progress notes for the provision of all DMC-ODS services provided under this Agreement. b. Each progress note shall provide sufficient detail to support the service code selected for the service type as indicated by the service code description. c. Progress notes shall include all elements specified in BHIN 22-019, whether the note be for an individual or group service, and shall include: i. The type of service rendered ii. A narrative describing the service, including how the service addressed the client’s behavioral health need (e.g., symptom, condition, diagnosis, and/or risk factors) iii. The date that the service was provided to the beneficiary iv. Duration of the service, including travel and documentation time v. Location of the client at the time of receiving the service vi. A typed or legibly printed name, signature of the service provider and date of signature vii. ICD-10 code viii. Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS) code ix. Next steps, including, but not limited to, planned action steps by the provider or by the client, collaboration with the client, collaboration with other provider(s) and any update to the problem list as appropriate. d. Contractor shall complete progress notes within three business days of providing a service, with the exception of notes for crisis services, which shall be completed within 24 hours. e. Contractor shall complete a daily progress note for services that are billed on a daily basis, such as residential and inpatient services, if applicable. f. When a group service is rendered by the Contractor, the following conditions shall be met: g. A list of participants is required to be documented and maintained by the Contractor. h. If more than one provider renders a group service, one progress note may be completed for a group session and signed by one provider. Contractor shall ensure that in this case, the progress note clearly documents the specific involvement and the specific amount of time of involvement of each provider during the group activity, including documentation time.