Provider Name and Credentials

The complete legal name of the therapist or provider who rendered the services, along with their professional credentials.

Client Name and Date of Birth

The client's full legal name and date of birth must be clearly visible on every page of the clinical record.

Care Delivery Method

The documentation must explicitly state the modality of service delivery: whether the session was conducted remotely (virtually, via telehealth) or physically in the same location (in-person).

Service Modality

Clearly identify the type of session conducted. Common modalities include individual therapy, group therapy, family therapy, couples therapy, or collateral sessions.

Client Location

For telehealth services, the documentation should specify the client's physical location during the session (e.g., "client at home," "client at work," "client at a designated telehealth site").

Provider Signature and Date

The documentation must include the legible signature (electronic or handwritten) of the provider who conducted the session, along with the date the note was signed.

Date of Service

The specific calendar date on which the therapy session occurred. This is distinct from the date the note was signed.

Session Start and Stop Times

Precise recording of when the session began and ended, including the calculation of the total duration.

Attendees

If individuals other than the identified client(s) were present, their full names and relationship to the client should be noted.

Diagnostic Statement Present

A diagnostic statement is present in the progress note, including either ICD-10 codes or DSM 5-based language identifying the client's primary and/or secondary mental health diagnoses. The diagnosis may appear in the note body or header.

Presenting Problem

A clear, concise statement of why the client sought services or is attending the session. This section should detail the client's current symptoms and behaviors, their severity (e.g., mild, moderate, severe), and how these issues are impacting their daily functioning (e.g., work, relationships, self-care).

Goals Addressed in Session

A clear link between the session's content and the measurable goals established in the client's treatment plan.

Measurable Goals

The goals themselves, as stated in the treatment plan and reflected in the session note, must be specific, measurable, achievable, relevant, and time-bound (SMART). They should logically follow from the client's assessment and diagnosis.

Interventions Utilized

A specific description of the therapeutic techniques, strategies, or activities employed by the provider during the session.

Client Response to Interventions

An objective observation and description of how the client reacted to the interventions used. This includes their engagement, understanding, emotional response, and any immediate changes in behavior or perspective.

Risk Assessment

Documentation of a thorough assessment of any current or historical risk for suicide, homicide, or self-harm. This includes inquiring about ideation, plan, intent, access to means, and protective factors. If risk is present, the note should detail safety planning and interventions.

Mental Status Examination

A systematic observation and description of the client's current mental state, covering areas such as appearance, behavior, speech, mood, affect, thought process, thought content, perception, cognition, insight, and judgment.

Plan

A forward-looking section outlining the next steps in the client's care. This includes scheduling the next session, any referrals made (e.g., to a psychiatrist, support group, medical doctor), homework assignments for the client, any modifications to the treatment plan objectives, and, if applicable, the anticipated discharge date or criteria for discharge.

Intensive Level of Care

When a client's risk of harm to self or others escalates, the documentation must detail the specific actions taken to move the client to a higher level of care. This criterion is only applicable if the client's risk has escalated to a point requiring a more intensive level of care.

Current Symptoms and Behaviors

A report of the specific symptoms and behaviors the client is experiencing at the time of the session. This serves as an ongoing assessment that tracks fluctuations and changes from the previous session, providing the clinical rationale for the session's interventions. This should include the client's subjective report and the therapist's objective observations.

Progress Towards Goals

A direct and evaluative statement on the client's movement relative to the specific treatment plan goals addressed in the session. This assessment must be based on data from the session (e.g., client reports, behavioral observations, skill application) and justifies the continuation or modification of the treatment plan.

Specific Services Rendered

The note must clearly describe the specific therapeutic services provided, justifying the CPT code billed. This includes the modality, duration, and interventions. For extended sessions (e.g., 90837), a clear rationale for the additional time, linked to acuity, complexity, or risk, is essential. For psychological testing, the assessment name, clinical reason, and time spent must be documented.