CLINICAL NOTES
TRAINING
Frances Marley, M.Ed., LPC, NCC I Clinical Services
Supervisor
Odyssey House Louisiana, Inc. Inpatient Services
AGENDA
Why Document
When to Document
Regulatory Guidelines
Group Notes
Individual Notes
Special Considerations
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If it’s not documented, it didn’t
happen.
-Unknown
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WHY
DOCUMENT
o Regulatory Guidelines
o Use in Future Documentation, e.g. ,CCRs
o Professional Liability
o Developing an Essential Skill
REGULATORY GUIDELINES
o Odyssey House Louisiana, Inc. (OHL) is a behavioral
health service provider under the Louisiana
Department of Health (LDH) Medicaid Program.
o As a behavioral health service provider, OHL and its
staff is required to adhere to the rules and regulations
of LDH’s Medicaid Services Manual.
o Chapter 2, Section 2.6: Record Keeping of Medicaid
Services Manual-rules and regulations for member
(client) records.
o Service/progress notes document the
services/progress billed. Service/progress notes must
reflect the service delivered and are the “paper trail” for
services delivered.
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SERVICE/PROGRESS
NOTE
REQUIREMENTS
I. Content of each delivered service, including the
reason for the contact describing the goals/objectives
addressed during the service, specific intervention(s),
progress toward functional and clinical improvement.
II. Clearly document that the services provided are
related to the member’s goals, objectives, and
interventions in the treatment plan, and are medically
necessary and clinically appropriate.
III. Specific interventions delivered including a
description of what materials were used when
teaching a skill.
IV. Each member’s response to the intervention,
noting if progress is or is not being made.
V. Observed behaviors if applicable.
VI. Plan for next scheduled contact with member
VII. Sufficient detail to support the length of the
contact
VIII. Be specific enough so a third party will
understand the purpose of the contact and supports
the service and claims data
APPLYING LA MEDICAID
REQUIREMENTS
I.
Therapeutic Services Provided and Rationale
i. The client’s goals/objectives addressed
ii. Interventions the counselor used
iii. The client’s progress toward the goal of
treatment
II.
How the Services Related to Treatment Plan & Medical
Necessity/Clinical Appropriateness
i. Relevance to goals, objectives, and interventions in
treatment plan.
ii. Medically necessary (as defined by Louisiana
Medicaid Program)
https://nashp.org/state-definitions-of-medical-necessity-under-themedicaid-epsdt-benefit/
iii. Clinically appropriate
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APPLYING LA MEDICAID
REQUIREMENTS
III. List materials used, e.g., handouts, videos, recordings, etc.
IV. Document how each client reacted to the service and whether or
not the service helped them reach their goals.
V. Describe the client’s behavior during the session.
VI. Note when you will follow-up with the client.
VII. The note should have enough detail to justify the amount of time
spent in a session.
VIII. Include enough detail so an outside party could read the note
and know why the service was relevant to the client’s treatment.
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APPLYING LA MEDICAID
REQUIREMENTS
Group Note Example
Group Note Details:
Clients participated in a group therapy session centered on the impact of societal
factors on individuals with substance use disorders. The aim of this session was
to assist clients in understanding factors that have contributed to their substance
use and empowering them to challenge these factors to improve their recovery
outcomes. Clients were educated on and given the opportunity to reflect and
process the ways society negatively impacts individuals with substance use
disorders. Clinician and clients discussed how socioeconomic status, systemic
racism, incarceration, stigma, and lack of access to education, treatment, and
resources impacts the development, treatment, and prognosis of substance use
disorders. Clients shared their experiences of coping with substance use
disorders and how societal factors impacted their condition and life circumstances.
Clients received feedback on their experiences from clinician and peers. Clinician
validated clients’ experiences and encouraged them to consider how they can
challenge oppressive societal factors with the goal of decreasing the likelihood of
relapse and other negative outcomes.
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APPLYING LA MEDICAID
REQUIREMENTS
Individual Note
Client was present, alert, and actively participated throughout the
session. He shared that he was incarcerated for four years due to a
drug possession charge in a school zone and when he was released,
he felt alienated from society and continues to struggle to get back on
his feet due to his criminal record, the financial burden of being on
parole, lack of job skills, and trauma associated with being
incarcerated. Counselor validate client’s experience and feelings and
encouraged him to reach out to local re-entry organizations. Clinician
also utilized CBT techniques to assist client in identifying and
challenging negative beliefs he has about his life for the overall goal of
relapse prevention. Counselor encouraged client to seek trauma
focused therapy to address his experiences while incarcerated when
he has been sober longer, feels more stable, and is ready to process
traumatic events. Client was receptive to these interventions,
demonstrating progress towards his goals of gaining insight into his
addiction and developing a discharge plan that is conducive to his
sobriety. Counselor will meet with client individually on 10/30 to
provide outside therapy resources and information on re-entry
programs.
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DID THIS NOTE MEET LA MEDICAID REQUIREMENTS?
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Reason for contact
Goals/objectives addressed
Specific interventions
Progress made towards functional/clinical improvement
Related to client’s goals, objectives, and interventions in
treatment plan
Medically necessary
Clinically appropriate
Materials used to teach a skill
Client’s response to intervention
Progress
Observed behaviors
Plan for next scheduled contact
Supports length of service
Third party would understand the purpose
Supports service and claims data
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APPLYING LA MEDICAID
REQUIREMENTS
Individual Note Example
Counselor met with client for scheduled weekly one-hour individual session.
Client presented as normal/euthymic and spoke clearly with a normal affect.
He was dressed appropriately. Clinician asked client how he was feeling after
a verbal altercation he had with another client the previous day. Client
reported that he was feeling “better” about the incident and that he had
reflected on it since. He reported that the encounter made him realize that
disrespect and anger are significant triggers for his substance use. Client
also noted that he was proud of himself for not escalating the situation
further and walking away which he has struggled to do in the past. Clinician
validated client’s experience and feelings and asked him to consider other
situations he may encounter in the future when he would need to walk away
to protect his sobriety. Client and counselor discussed setting boundaries
with friends and family who use and client agreed to make specific plans for
how he will set boundaries. Counselor provided him on a DBT skill DEAR
MAN informational worksheet to look over. Client expressed appreciation.
Clinician will follow-up with client on 10/30 regarding his progress towards his
goal of improving his communication skills and boundaries.
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DID THIS NOTE MEET LA MEDICAID REQUIREMENTS?
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Reason for contact
Goals/objectives addressed
Specific interventions
Progress made towards functional/clinical improvement
Related to client’s goals, objectives, and interventions in
treatment plan
Medically necessary
Clinically appropriate
Materials used to teach a skill
Client’s response to intervention
Progress
Observed behaviors
Plan for next scheduled contact
Supports length of service
Third party would understand the purpose
Supports service and claims data
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Special Considerations
Clients Isolation
If a client is placed in isolation due to COVID-19 or
any other reason, they must have daily
documentation and need to have daily therapeutic
interventions.
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THANK YOU
Frances Marley, M.Ed., LPC, NCC I Clinical Services Supervisor
Inpatient Services
Odyssey House Louisiana, Inc.
fmarley@ohlinc.org
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