67:62:08:12Progress notes.

A mental health staff member must record progress notes in the client's case record that substantiate all services provided. A mental health staff member must document the counseling sessions with the client, summarize significant events occurring, and reflect goals and problems relevant during the session, and any progress in achieving those goals and addressing the problems in the progress notes. A mental health staff member must also include attention to any co-occurring disorder as it relates to the client's mental disorder in the progress notes. A progress note must be included in the client's clinical record for each billable service provided. Progress notes must include the following for the services to be billed: (1) Information identifying the client receiving services, including the client's name and unique identification number; (2) The date, location, time met, the units of service of the session, and the duration of the session; (3) The service activity code or the title describing the service code; (4) A brief assessment of the client's functioning; (5) A description of what occurred during the session, including the specific action taken or plan developed to address unresolved issues for the purpose of achieving treatment goals or objectives; (6) A brief description of what the client and the provider plan to work on during the next session and work that may occur between sessions, if applicable; and (7) The signature and credentials of the staff providing the service.

Source: 43 SDR 80, effective December 5, 2016; 50 SDR 63, effective November 27, 2023.