MHPOffice supports splitting documentation between Progress, and Psychotherapy categories. This helps support the governments requirement to split your documentation. This categorization is optional, but is available for those who need it.
There is some confusion in the mental health community regarding which one is which, so we thought it would be useful to clarify the definitions.
Progress Notes become part of the clinical record, which may be requested by the client at any time.
Progress Notes are the evidence of a provider’s services to or on behalf of a client and relate to the client’s progress in treatment. Notes are filed in the clinical record and must contain the clinical details to support the medical necessity of each claimed service and its relevance to the Client Plan.
In order to submit a service for reimbursement, some insurance providers require a complete and filed Progress
Note for that service.
Progress Notes must clearly relate to the mental health objectives & goals of the client, rather than others tangentially related to the client.
Each Progress Note must “stand on its own” regarding Medical Necessity; identifying a clear link to the Client Plan helps meet this rule
Psychotherapy notes are defined in CFR 45, Part 164.501 as " notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the individual's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling session start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: Diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date."
Psychotherapy Notes differ from regular clinical records and receive special protection under HIPAA (CFR 45, Part 164.524) from other clinical records which may be exchanged between providers and the MHP (Mental Health Professional) without specific permission from the client. Physically integrating the excluded information and protected information into one document does not make the excluded information protected. (CFR5)
Psychotherapy Notes that are not filed separately from the clinical record, or that contain excluded information, no longer receive special protection under HIPAA. Those notes are subject to review by the MHP and would be seen by the client if he/she so requested. Psychotherapy Notes that are maintained separately and do not contain excluded
information would only be disclosed via legal action or with the client’s release.
LegalMHPToolbox.com is not providing this information on a legal basis, but simply as a refresher regarding the overview and intended purpose of the Progress and Psychotherapy notes process within MHPOffice. If you have any questions regarding what or how to document your sessions, please contact a supervisor, legal professional, or other certified health professional who is qualified to address those issues.
If you discover any inaccuracies regarding our definition here, or the use of notes in MHPOffice, feel free to open a support ticket to discuss how we may improve our compliancy. We are here to serve you!