Section 2060.470  Progress Notes and Documentation of Service Delivery

a)         Patient progress shall be documented by note in the patient record and shall be consistent with the assessment and treatment plan goals and objectives.  At a minimum, progress notes include a chronological documentation of progress in treatment, any change in patient behavior, and a description of the patient's response to treatment.  Progress notes also document patient outcomes, toxicology results, missed dosing for patients on MAR, referrals for case management, recovery support, and any other incident that may have an impact on patient progress in treatment.

b)         Progress notes shall document each service delivered, location of the service delivery and the date, time, and duration of each service.

c)         Progress notes shall include the name and credentials of the individual who provided the service.  As applicable, progress notes shall also be signed and dated by the individual making the entry.  Electronic signatures or initials must meet all specifications for electronic signature specified in Section 2060.370(d)(6).

d)         Service delivery can be summarized in a progress note prior to each continued service review for patients in Level 1 or 3.1 care, every 14 calendar days for patients in Level 2 care, and daily for patients in Level 3.2, 3.5 or 3.7 care.

e)         Any progress note that includes a subjective interpretation of the patient's progress shall include a description of the actual behavior.