Keeping progress notes on Headway

During the first session, providers will complete a diagnostic evaluation of the client. From this evaluation, the provider develops a treatment plan with specific goals for the client. This plan creates a thread from the initial evaluation through the progress notes, where providers track how well the client is progressing toward these goals over time.

 

Differences between progress notes and psychotherapy notes

Progress notes communicate the important details of a client’s care and diagnosis and are a key element of a client’s medical records. They include the details of the session including session start and stop time, treatment modalities, symptoms, progress toward goals, and plan.

Progress notes are legally required for every session billed to insurance.

Psychotherapy notes are solely for the purpose of the provider who writes them. These notes include details that might help providers remember the specifics of a session, and are not intended to be seen by anyone else.

Our platform is not meant for storing psychotherapy notes.

 

Making your notes meet insurance standards

Here are some of the most important items to include to meet insurance standards:

• Client name & date of birth
  • This must be listed on every page
• Informed consent 
  • If performing telehealth services, also include telehealth consent including reference to HIPAA compliant software
• DSM 5 or ICD-10 diagnosis
• Date of service
• Session length (all timed codes must include the length in minutes)
  • We've included fields in the appointment confirmation to add actual start and stop times to better meet insurance standards
  • Length of therapy must be included if therapy was provided in addition to evaluation and management services
• Session Location (include whether virtual or office address. If performing telehealth services, indicate the virtual platform)
• A risk assessment and safety plan, if relevant  
  • If you identify risk, include and review a safety plan with the client
• Assessment and plan
  • Include a summary of the client's treatment response and progress toward the client's goals as outlined in the treatment plan
  • Indicate whether the client's symptoms have improved, maintained, or escalated 
• Provider name and credentials (you can use /s/ to indicate an electronic signature on Headway, if you're pasting in a note you wrote elsewhere. Example: /s/ John Q. Public, LCSW)
  • Full name & NPI / License Number at the top of notes, or in the header
  • With the date that the notes were signed

While some of this information may be repetitive with what Headway collects automatically in your calendar, insurance companies require these details to be included directly in your notes. For more information, check out the top 10 items most commonly missing from notes.

 

Recommended progress note templates

Keeping notes that meet insurers' standards can be complicated. The clinical templates outlined below offer structure and support for your notes so that you can focus on providing care.  Using the structured templates is optional, so long as your notes follow our guidelines.

We've also developed sample templates for your reference:

• Content warning: While fictitious, these documents contain example symptoms and risks that may be sensitive or upsetting to some viewers.
  • Intake example 
  • Progress note - 45 min example
  • Progress note - 60 min example

 

 

Using clinical templates on the Headway platform

When confirming a session, you'll see a progress notes section. From there, you'll be given a few options.

To use one of our clinical templates:

1. Select Fill out template
   
2. Under Template, you can select an option from our template offerings using the dropdown menu
   
3. Once a template has been selected, fill out all applicable fields
   • Our system will let you know when you’ve missed a required field
   • You will also be given the option to pre-fill the template based on a previous session
4. You’ll be given the option to save your work and Save draft or Sign and submit your note
   
   
   • If you select Save draft, you can save all the information you've inputted, and come back to finish it when you're ready
   • If you select Sign and submit, the session will be confirmed and your progress note will be completed & attached to the session

 

Templates to choose from

Currently, we offer the following options:

• Diagnostic eval: Medical services  
  
  • Initial assessment note for prescriber completing a diagnostic evaluation with medical services
• Progress note: Medical services 
  
  • Progress note for prescriber completing a follow-up evaluation with medical services
• Intake: Therapy
  • Initial assessment note for therapy
• Progress note: Therapy and medical services 
  • Progress note for prescriber completing a follow-up evaluation with medical services and therapy
• Progress note: SOAP
  • SOAP template for progress note (commonly used by talk therapists)

 

 

Choosing the best template

 

Diagnostic eval: Medical services  

 

Progress note: Medical services

 

Intake: Therapy

 

Progress note: Therapy and medical services

 

Progress note: SOAP

 

Adding an addendum to your progress notes 

To add an addendum to a progress note:

1. Select the applicable client from within the Clients tab in Sigmund
2. Navigate to the Clinical tab
3. Scroll down to the Past confirmed sessions section
4. Find the session date for the applicable progress note and click the carrot to show the session details
5. Click View Progress note
   
6. Click Add Addendum in the upper right hand corner
   
   
   1. If you previously used a template to complete the progress note, you will be prompted to add a free text addendum
      
      • You can specify any changes or additions directly within the free text box and the addendum will be saved along with the original note you submitted
   2. If you previously uploaded a progress note, you will have the option to add an addendum file in line or add a free text addendum
      
      • You will have the option to upload and save an addendum file with any changes or clarifying details
      • You can also use the free text option to specify any changes or additions; both options will enable you to save the addendum along with the original note you submitted
7. Once you have either uploaded your addendum file or added a free text addendum, by clicking Sign and submit addendum you are attesting that the info provided is true and accurate
   

 

Writing progress notes for CPT codes 90832-90838

The psychotherapy service codes 90832-90838 include ongoing assessment and adjustment of psychotherapeutic interventions and may include involvement of informants in the treatment process.

CPT Codes 90832-90838 describe psychotherapy for the individual client, although times are for face-to-face services with client and may include informant(s). The client must be present for all or a majority of the service.

In reporting Psychotherapy services, choose the code closest to the actual time:

• Less than 16 minutes, not reported
• 16 to 37 minutes, 90832 or 90833*
• 38 to 52 minutes, 90834 or 90836*
• 53 minutes or more, 90837 or 90838*

 

*90833, 90836 and 90838 – these are psychotherapy add-on codes performed with E/M service. 90837 notes must include explicit documentation of medical necessity if used for a client more than once a week - read more about using CPT code 90837 here.

Helpful tips on 90832-90838:

• CPT codes 90832-90838 may be reported on the same day as codes 90846 or 90847 when the services are separate and distinct.
• Use CPT codes 90839 and 90840 when psychotherapy is provided to a client in a crisis state.
• Use 90785 in conjunction with codes 90832-90838 when the diagnostic evaluation includes interactive complexity services.

Limitations:

Psychotherapy services are not considered reasonable and necessary when documentation indicates:

• Client has dementia with severe enough cognitive defect to prevent establishment of a relationship with the therapist.
• Client with severe and profound mental retardation. Severe mental retardation is defined as an IQ 20-34 and profound mental retardation is defined as an IQ under 20.
• Treatment primarily included teaching grooming skills, monitoring activities of daily living, recreational therapy (dance, art, play) or social interaction.
• Family therapy sessions with client whose emotional disturbance would be unaffected by changes in patterns of family interactions (i.e. a comatose client).
• Psychotherapy codes should not be used when an E/M code would be more appropriate.
• Psychotherapy services should not be reported for Activities of Daily Living (ADL) training or socialization activities.
  
  

Psychotherapy documentation checklist for CPT codes 90832, 90834, and 90837

All of the items below must be present to be considered complete. 

• Client's full name and date of birth (DOB) must be listed on every page
• Date of service (this should be indicated on the first page, at minimum)
• The location of the session, whether it's in-office or via telehealth
  • For telehealth sessions, document where the client is located (at home or elsewhere)
• Client's chief complaint or presenting problem
• The exact duration of face-to-face time spent with the client, excluding time for chart review or documentation
• Appropriate CPT code, based on the actual face-to-face time spent with the client
• Mental status exam, covering at least three categories such as mood, affect, thought, orientation, and physical presentation
• Person-centered details like behaviors, descriptions, or quotes
• Diagnostic statement that outlines the client’s symptoms and the criteria used to determine their diagnosis
  • Ensure consistency with the diagnosis on your confirmation
• Risk assessment
  • Note: If the risk is anything other than low or none, include a safety plan
• Therapeutic interventions or modalities used during the session, such as DBT, CBT, or motivational interviewing
• Demonstrate the client’s progress, indicating whether they are improving, deteriorating, or maintaining their condition
• The treatment plan and/or goals (what is the desired outcome for the client)
• Client's progress towards the treatment plan/goals, which can be as simple as indicating if they are progressing, regressing, or maintaining
• Date of the next scheduled session
• Valid provider signature (should include the provider’s first and last name, credentials, and the date signed)
  
  

How Headway keeps progress notes secure

We’re trusted with individuals’ most sensitive information, and take protection very seriously. We’ve built a secure data infrastructure and platform, maintain SOC 2 and HIPAA compliance, and follow industry best practices regarding cloud infrastructure and encryption. Headway does not sell or upload any data to third party publishers.

 

Storing your progress notes with Headway

You’re not required to use our templates or notes system, but it is required that you’re keeping notes for every session and that you produce them promptly (within three business days at most) of a request. If this is your preference, please select Note saved elsewhere.

If you do want to add your documentation on Headway, we make it simpler through guided templates.

 

Exporting client documentation

If you have your notes stored on the Headway platform, you can download them directly from the provider portal.

To do this:

1. Visit your Clients list 
2. Click the name of the client you'd like to download notes for 
3. Click on the Clinical tab
4. Scroll down to Past confirmed sessions
5. Click into the session(s) you'd like to download the progress notes for
6. Click Download note