"Diary-style” documentation tracks updates over multiple dates in a single entry. While this may seem efficient, this format is not compliant with insurer or CMS standards and cannot be used to support billed services.
This article breaks down what diary-style documentation looks like, why it’s a problem, and how to align your workflow with behavioral health documentation standards.
This style typically looks like a running log of the client’s progress across several dates, such as:
- “5/10: Client reported sleep issues and increased anxiety.”
- “5/17: Reviewed medication options; discussed coping strategies.”
- “5/24: Client feeling better, no med changes planned.”
Instead of creating a standalone note for each session, this approach condenses multiple visits into a single document.
Why diary-style documentation is a compliance concern
Each billed date of service must have its own distinct progress note. This is a consistent requirement across commercial insurers, Medicaid plans, and Medicare. When a note includes multiple dates or references to prior sessions without clearly separating or labeling them, it creates several risks:
- Ambiguity around what was done on the billed date
- Missing time-specific clinical decision-making or interventions
- Potential errors in billing or medical record audits
Although it seems that an auditor would know that the section labeled with past dates refers to previous sessions, and that the rest of the note is for the current visit, auditors are not allowed to assume or infer anything.
Auditors are required to evaluate documentation exactly as it is written. If a note does not explicitly state what occurred on the billed date of service, it can't be considered valid support for the claim.
“It may seem like an auditor would just know which part of a note applies to the current date of service—but we are not allowed to assume or infer anything. If it’s not clearly documented, we cannot count it.”
— Jessica Belvin, CPC, CPMA, Senior Medical Coding Specialist
The standard: One Note per date of service
Documentation should reflect what occurred during a specific encounter—not a running list of updates. According to widely accepted payer standards and CMS guidance:
A compliant note must include:
- The date of service
- The client’s presentation during that session
- Interventions provided (e.g., therapeutic techniques, medication decisions)
- Outcomes or treatment updates based on that day’s encounter
- Any relevant start/stop times (e.g., for add-on therapy billing)
- All relevant clinical details like medication name, dosage, and frequency
Referencing prior dates in your note
It’s okay to briefly reference prior sessions (e.g., “as discussed last session…”), but the focus of the note should remain on the current date of service.
If you include historical information in the note, be sure to:
- Clearly label which section is historical (e.g., “Background from previous sessions”), OR
- Include a statement such as: “All content below reflects the client’s status as of [insert date of service]. Any historical information is limited to the section above.”
This helps eliminate confusion and signals to the auditor that the remainder of the note is date-specific and appropriate to bill.
How diary-style notes can go wrong
Let’s say a provider documents a three-week timeline of care in a single note, referencing several topics across dates. When billing one of those dates, the note doesn’t clearly indicate:
- What happened on that day
- Whether a session even took place
- If treatment was delivered, adjusted, or reviewed
Even if all of this happened, the documentation fails to support it in a way that meets compliance standards. That gap is what puts both providers and billing platforms at risk.
How to get it right
Here are best practices to align with payer and CMS expectations:
- Create a separate, finalized note for each session
- Ensure each note reflects the unique care delivered that day
- Avoid pasting running logs or multi-date summaries
- If referencing history, label it clearly and clarify which parts are specific to the billed date
- If using an external EHR, upload a PDF of the finalized session note—not a copy-paste into Headway’s template or free text box. There should not ever be two versions of a medical record
- Confirm that clinical details—especially medications—are complete and accurate for the session
Key takeaway: One date, one note
Every date of service you bill for must be backed by a standalone, date-specific note.
Diary-style documentation—even when well-intended—makes it difficult to determine what happened when, and puts the integrity of your clinical documentation at risk. By creating structured, session-specific notes and avoiding ambiguous timelines, you help ensure compliance, reduce claim denials, and improve continuity of care.