How to Write a Progress Note for a Scheduled Service

Note: to document a progress note for a group, see How do I write a group progress note?

1. On your Appointments for Today widget, click on the time link for the service you’re documenting.
   
2. This opens the service note. Complete the service details.
   1. Confirm/Enter Mode of Delivery.
   2. Enter Face to Face Time. Under CalAIM Payment Reform, this is what is used for billing. Enter Travel Time and Documentation Time if applicable.
   3. Enter Evidenced-Based Practices if applicable.
      
   4. For certain procedures, an Emergency Indicator field will appear. Enter whether this was an emergency or not. 
      
3. If the status is show, you may now click on the Note tab. Complete the progress note tab. This note type may look different depending on the procedure code you have chosen. Most will include 3 fields: the Problem List section, the Note section, and the Care Plan section.
   1. If you want to add problems to the problem list, you can do so here. Follow the instructions in How do I add a problem to the Problem List?.
      
   2. Select which problems you addressed in today’s session.
      
   3. Enter your note in the Note section. This should include all your usual clinical information, such as your interventions and the client’s response to the interventions.
      
   4. Enter your plan of care in the Care Plan section. For services that require a treatment plan, this is where the treatment plan is entered. This information will pull forward from the most recent service note in the same program. There may be text templates available for specific treatment plan requirements.
      
4. The Billing Diagnosis tab will show you which diagnoses will be pulled onto the billing. You should generally ignore this tab for ongoing services. However, if you need to change the billing order, for example you want this note to focus on the secondary diagnosis, you can re-order the diagnoses to match your service without changing the overarching diagnosis form.
   
5. When you are complete, click Sign.