ARSD 67:61:07:08. Progress notes

The direct care provider must record at least one progress note in the client's clinical record each week when services are provided for any program, other than a prevention program. Progress notes must be included in the client's clinical record and substantiate all services provided. Progress notes must document counseling sessions with the client, summarize significant events, reflect goals and problems relevant to the session, and reflect any progress in achieving those goals and addressing the problems. Progress notes must include attention to any co-occurring disorder, as it relates to the client's substance use disorder. A progress note must be included in the client's clinical record for each billable service provided. In order for a service to be billed, the progress note must contain: (1) Information identifying the client receiving the service, including the client's name and unique identification number; (2) The date, location, time met, the units of service of the counseling session, and the duration of the session; (3) The service activity code or the title describing the service code; (4) A brief assessment of the client's functioning; (5) A description of what occurred during the session, including the specific action taken or plan developed to address unresolved issues for the purpose of achieving identified treatment goals or objectives; (6) A brief description of what the client and the clinician plan to work on during the next session, and work that may occur between sessions, if applicable; and (7) The signature and credentials of the staff providing the service.