About your annual chart review

Everything you need to know about Headway's annual documentation review — what it is, how it works, and what to expect.

How it works

What the annual chart review is

Once a year, Headway reviews a sample of your notes against the documentation and safety standards health plans and licensing boards already hold you to. It's required for every provider on Headway, and you'll always get notice before yours opens.

The standards cover two things: that your notes capture key safety elements (risk, history, medication), and that they meet the documentation requirements attached to the claims Headway submits on your behalf. They're published here so you can see exactly what's checked:

• Talk Therapist Guidelines
• Psychiatric Provider Guidelines

Most providers have at least one item flagged. That's expected — it's what the short courses are for — and you never need to edit notes you've already written.

Why Headway does this

Health plans review notes across Headway's network every year, and their expectations for documentation are rising. This review is how we help you get ahead of that rather than be surprised by it: one scheduled review, announced in advance, against standards you can read first, instead of a records request you didn't see coming. Meeting these standards is also how we keep the rates we've negotiated for you protected.

Headway's clinical team designed the review — the process, the evaluation tool, the courses, and the clinical review you can request if you disagree with a finding. The standards themselves aren't Headway's invention.

How your notes are reviewed

An automated evaluation tool checks each note against the published standards. Intake notes are checked for clinical and safety elements; progress notes for the same, plus documentation requirements tied to billing. Every flag shows what was missing and where, so you can check it against your own note.

If you think a finding is wrong, request a clinical review from your findings page. A member of Headway's clinical team will read your note and reply within 3-5 days days. Any decision that affects your standing on Headway comes from that team, following a standard process — never from a flag alone.

How to submit your notes

For your chart review, we ask for documentation from five of your clients from the past 12 months. From each client, we'll ask for:

• One intake note
• One progress note

When the review opens, you'll see a list of the five clients and 10 notes we're asking for in your Chart reviews tab in the provider portal. We pre-fill anything that's already documented on Headway, so you only need to upload what's missing.

Upload each note as a PDF. Each note upload should be a single file, and if your EHR exports separate documents (e.g. a note plus a mental status exam), you should combine them into one PDF before uploading. Preview (available on Macs) or similar tools can merge PDFs without PHI leaving your device.

You can do this all at once or as you go — you have 30 days from when the review opens. You’ll receive both an email and in-product notification to let you know when this period has started. The exact deadline is shown in your Chart reviews tab.

Understanding your findings

Once your notes have been reviewed, you'll see a results page in the Chart reviews tab showing what came back. Each finding falls into one of these categories:

• Passed — Your notes met the standard for that item. No action required.
• Flagged
  • Red (critical) — We found something that needs your attention. We'll walk you through what we found, what to fix, and how to confirm the change going forward. Typical examples here include missing checks related to suicide risk, self-harm, and client safety.
  • Orange — We noticed something worth mentioning. Action not required, but recommended to keep in mind for future notes to stay ahead of potential issues. 

Each finding comes with an explanation so you know exactly what was flagged and why. Depending on what was flagged, you may need to complete coursework, then complete a light follow-up period where we check notes as you confirm sessions.

Learning courses and next steps

Depending on your findings, you may be enrolled in one or more short, focused courses.

• Each course is designed by Headway's clinical team.
• They usually take 30–60 minutes.
• You're enrolled automatically — you don't need to find or sign up for anything.
• Most courses end with a short scenario you'll work through.

You’ll receive an email and in-product notification when your courses are assigned. You have 30 days from when you receive your findings to complete the courses. If you don't pass a given course on the first try, that’s okay. You’ll get detailed feedback and a second chance to get things right. Note that if you had fewer than five intake notes available, you may also be assigned courses to confirm you know how to meet the standards.

Follow-up period

The follow-up period is how we confirm the changes have taken hold in your day-to-day notes, and happens after you have successfully completed your coursework.. We won’t require this if your 10 requested notes all passed. If applicable, you'll be required to upload notes when confirming sessions for 30 days. You'll be able to see feedback on each note in the Chart reviews tab as you go, so you can get a sense of how you’re doing. We’ll share your overall result after the 30 days — usually within seven days of the 30-day window closing. 

After 30 days, we'll summarize the findings from your notes.

• If your notes pass most checks and address all critical issues, your annual chart review will be complete.
• If there are still critical issues, or a consistent pattern of missing a single check repeatedly, we'll give you a second 30-day window to try again.
  • In the rare event that you do not pass for two 30-day periods in a row, we'll escalate to our clinical team, who will reach out to you directly. Note that reaching this stage may impact your standing with Headway.

The follow-up period is temporary and ends as soon as improvements are confirmed — Headway will not continue to require note uploads after this time.

If you document outside of Headway

We understand that some providers prefer to document outside Headway. We respect your preference and aren't asking you to make a permanent change. We'll just need you to upload your notes when confirming sessions during the annual review period. That means:

• 10 notes upfront at the beginning of the review
• If we found critical issues, continue uploading notes for your Headway clients when you confirm sessions during the 30-day follow-up period.

Once you pass the review, Headway generally won’t require you to upload more notes until next year's review. While it’s possible an insurer may request a separate review at some point, we expect this annual review will also make insurer requests throughout the year less likely.

Timeline at a glance

The journey, step by step

Your chart review moves through up to four steps. You may not see all of them — if your notes pass after Step 2, you'll skip straight to Complete and you're generally done for the year.

Step 1 — Note submission (up to 30 days from when we email you)

Upload the requested notes through your Chart reviews tab. We’ll email you and alert you in your portal when this phase begins. We pre-fill anything already on Headway, so you only upload what's missing. You can do this all at once or over time — the 30 days is your deadline, not an estimate of how long it takes.

Step 2 — Under review (a few days)

Your notes are reviewed against Headway's documentation standards. Nothing you need to do here — keep practicing as normal.

Step 3 — Findings and courses

You'll see your results in the Chart reviews tab. Each check is marked Passed or Flagged, and every flagged check comes with a clear explanation. Flagged checks are either orange or red (critical). Critical checks carry the most weight. Depending on what was flagged, you’ll move on to coursework. 

One or more short, focused courses, each taking around 30–60 minutes. You're enrolled automatically. You'll have up to 30 days to complete it from the time we share findings, with a second 30-day window if needed.

For psychiatric providers only: if a critical patient safety risk was flagged, you'll also complete a response for each one.

Step 4 — Follow-up period (30 days, if assigned)

After you successfully complete coursework, you’ll enter a follow-up period. For 30 days, add a note when you confirm sessions — just a couple of clicks. You may see some findings as you upload to get a sense of how things are going. After 30 days, we’ll share your full results. If certain critical checks aren't met in the first window, you'll get a second 30-day window to keep going (with about a week in between as we tally results). This second 30-day window is temporary and ends when improvements are confirmed.

For psychiatric providers only: if a new critical patient safety risk comes up while the follow-up period is open, we'll ask you to respond to it before the period closes.

If checks aren’t met after multiple attempts: In rare cases — for example, two unsuccessful coursework attempts, or repeated issues across both follow-up rounds — your review moves to a one-on-one conversation with Headway's clinical team. The goal is to understand what's going on and find a path forward together. Your network standing with Headway may be affected. We'll always tell you exactly what's happening and why before any next step. 

Where to get help

• You can always start a chat with us for general questions on how to use the Chart reviews tab, upload notes, or anything else about the process.
• When you receive findings on your notes, you’ll also see links to ask questions or request a review if you think we got something wrong. These requests will be sent to our clinical team for review, and you’ll get an answer within a few days.

Common questions

What counts as an intake note?

An intake note is your clinical record of the first session with a client and establishes the foundation for ongoing treatment. It should include documentation of the reason for seeking care, relevant clinical history (including prior treatment, substance use, and trauma history), mental status (MSE), risk assessment, and the diagnosis supported by symptoms. Separate documentation, such as a treatment plan, is not required. For specific information on what to include in an intake note, please see our Annual chart review guidelines for talk therapists article. 

Is this review required?

Yes. The annual chart review is a standard part of practicing on Headway. Every provider goes through one each year.

If you don't complete a step within its window, Headway's clinical team will reach out to work with you directly. The goal is always to help you finish..

Termination from Headway is reserved for situations involving a repeated pattern of safety risks or clear billing inconsistencies— and only after we've reached out directly to understand your situation and worked with you to get things right. We make such decisions following a standard process, and only after consulting with multiple members of our clinical team.

Who conducts the review, and who sees my notes?

Headway's clinical team built the annual chart review program, anchored on standards set by health plans and licensing boards. As part of the program, an automated tool managed by the clinical team gives you an initial review of your documentation.

Your notes stay within Headway's review process; we don't share anything with insurers as part of this review. If you disagree with a finding, we make it easy to reach out to the clinical team and have it re-reviewed by a member of our staff.

What happens to my notes after the review?

We only use your notes to conduct this review and to confirm your documentation meets the standards described here. Headway limits requests, use, and disclosure of protected health information to what is minimally necessary to accomplish the intended purpose of the appropriate request, use or disclosure.

Do I need to go back and edit past notes?

No. The chart review is about improving your documentation going forward. Any changes apply to future notes only — you don't need to go back and revise notes you've already written.

How often do chart reviews happen?

Once a year. Every provider on Headway generally has one annual chart review. You'll always get a heads-up before yours starts.

Can this affect my standing on Headway?

For most providers, no. The chart review is a routine review — findings and education, not discipline. 

Your standing only changes in situations involving repeated unresolved critical findings, safety concerns, or billing accuracy problems that aren’t resolved after multiple attempts. If your standing is ever at risk, we'll reach out to work with you before making a final decision. Headway will tell you exactly what's happening and why.

Will Headway be reviewing all my notes going forward?

No. The review is temporary. It ends as soon as improvements are confirmed. Outside of your annual chart review, Headway does not routinely require your session notes.

What happens if I don't show improvement during the follow-up period?

Headway's clinical team will reach out to work with you directly.

In certain cases, if issues can't be resolved across both follow-up rounds and direct support, we may take further steps, up to and including termination from Headway. But we'll always tell you what's happening and give you the chance to work through it before we make a decision.

Is this different from an insurer audit?

Yes. This review is initiated by Headway and is proactive. We do this to get ahead of potential insurer audits. That means we can give you more time to complete each step, and by doing this review annually, we likely prevent several insurer audits from happening in the first place.

Can I dispute a finding?

Yes. If you think a finding is wrong, you’ll be able to request a review from a link next to your findings. A clinical or coding specialist will take another look. 

What happens if I'm on vacation when my chart review starts?

Each step has a 30-day window, which is built to absorb a week or two of time off without issue. If something bigger comes up — extended leave, a family situation — let us know through the support chat and we'll work with you on timing.

Will my clients know about the chart review? Is client consent needed?

No. The chart review is between you and Headway. Your clients don't get notified, and the notes you submit aren't shared with them or with insurers as part of this process.

No separate client consent or release of information is needed for notes requested as part of Headway's chart reviews. Release of records to Headway and to health plans does not require additional patient authorization because they are considered covered entities under HIPAA. Additional patient authorization or notification is not required for covered entities, per the “Permitted Uses and Disclosures” section of HIPAA.  You can find more detailed information on this policy here.

Related articles

• General documentation guidance
• Guidance and resources on feedback for billing compliance
• Confirming sessions on Headway
• Audit records requests