Many of our mental health clients ask us about documentation requirements. I just attended a great webinar through AAPC (American Academy of Professional Coders.) It was very helpful in outlining what the documentation requirements are for mental health practitioners.
I’ll outline them here.
We all know we need provider name, patient name and date of service. One other critical piece of information is: time. Providers should always document the total amount of time spent with the patient.
The rest of the note would communicate the following information:
Subjective: report symptoms and psychosocial stressors
Objective: Report mental status
For example, changes from previous visit, mood, speech
Active Problems: List the diagnosis(s) here
Assessment: Objective report, progress and prognosis
Treatment Plan: Clinical treatments and recommendations