Note Type
Use this type of note if you saw a client in office for a one-on-one counseling session
Individual counseling progress note
Use this type of note if you saw a client in a group setting
Group progress note
True or false: multiple CM notes for the same day of service are billable
True
How long do you have to complete direct service documentation?
48 hours
If you didn't document it...
it didn't happen
Use this type of note to document that you reached out to the client by phone and they didn't answer
No bill
Use this type of note to document text messages to and from clients
No bill
True or False: an individual counseling note and diagnostic assessment on the same day of service are billable
False - fast-track tx plans are completed under CM
How long do you have to complete documentation if there was a crisis or mandated reporting event?
ASAP - same day or 24 hours
Dishonesty in documentation, including falsification of service documentation, is also known as...
Fraud
Use this type of note if you reached out to a client by phone and ONLY scheduled their next appt.
No bill
Use this type of note if you saw a client one-on-one over Zoom
True or false: All sessions should have accurate and precise start and end times
True
When is it more accurate and efficient to take notes on paper and then complete the electric note at a later time?
If we do not have electricity or CareLogic is down.
Internal disciplinary actions for fraudulent documentation range from blank to blank.
Written reprimand to termination
CM with client
This type of note is used to document intra-agency care coordination
Treatment Team (no-bill)
True or false: Concurrent, or collaborative, documentation improves the accuracy and efficiency of progress notes
True
Criminal charges for insurance fraud range from blank to blank
M1 to F3
Use this type of note if you spoke to a PO by phone to coordinate care for a client
CM with other
Use this type of note if you coordinated care with a community partner over Zoom
CM - with other - telehealth