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Mental Health Documentation Requirements

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

If you would like a Documentation Template, please email us at: We’re happy to send you a Template for you to use for your practice.

Happy Documenting!

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