Resources for quality documentation in Progress Notes

Progress notes MUST contain the following information:

• Client name

• Client DOB

• Date of session

• Exact start time and stop time of session

• Session number

• Date of next session

• Diagnosis 

• Location of session (office-based/ in person)

• If Telehealth with what HIPAA Compliant platform used (e.g. Google Meet, Doxy.me, VSEE, etc) and audio and/or video

Links for other helpful information:

• DVHA VT Medicaid Provider Manual Updates-2024

• VCR/Matrix Chart Review Document

Note completion rhythm and timeframe examples in an effort to enhance self- and community-care:

Documentation should be completed within 1 weeks of the Date of Service. With this in mind, here are a few suggestions of how to build time in your day to work towards ensuring that your documentation is complete while balancing your self-care and capacity.

• At end-of-day and/or start to the following work day

• Carve out X amount of time at end-of-day or beginning of next work day to dedicate to progress notes

• Administrative day or X hours/day for communication and notes