Get Psychiatric Progress Note/billing Form - Contra Costa Health Services - Cchealth

Filling out the Psychiatric Progress Note/Billing Form is an essential task for documenting mental health services provided. This guide will provide you with clear and supportive instructions to navigate each section of the form online effectively.

Follow the steps to complete the form accurately and efficiently.

1. Click 'Get Form' button to access the Psychiatric Progress Note/Billing Form and open it in your preferred editor.
2. Fill in the Name and MRN (Medical Record Number) at the top of the form. This information is crucial for identifying the client and tracking their care.
3. Enter the Date of Service. This is important for record-keeping and billing.
4. Indicate the RU number and the number of clients in the group session, if applicable. Proper documentation of these numbers is essential for accurate billing.
5. Fill out the Staff Number and Co-Staff Number along with the hours and minutes spent in each session. Be accurate as this affects billing and service documentation.
6. Document the travel time involved in the service provided. Enter the hours in the designated space.
7. Select the appropriate service strategies offered from the list provided, such as medication services, individual therapy, or crisis intervention.
8. Provide a brief description of the client’s profile, including their age, gender, current presentation, and the date of their last visit.
9. If an interpreter was involved, note their name and the language they provided services in.
10. In the Interim History and Observations section, summarize the client's progress and current symptoms or issues.
11. Conduct and document the targeted mental status exam findings, such as the client's orientation, grooming, mood, and insights.
12. List all current medications prescribed to the client, both psychiatric and non-psychiatric, and confirm the status of medication consents.
13. Record any objective data or lab studies that were reviewed during the visit, along with vital statistics such as height, weight, and blood pressure.
14. Document the current diagnostic impressions according to DSM criteria, noting any changes or observations from previous visits.
15. Detail any psychotherapeutic interventions that were administered, if applicable.
16. Outline the plan for continued service, including any laboratory orders, referrals, and coordination of care with other healthcare professionals.
17. Indicate the next appointment details, including who will be seen and when.
18. Finally, ensure that the MD/DO/NP signature and name is filled in appropriately at the bottom of the form for validation.
19. Review the entire document for accuracy and save your changes. You can also download, print, or share the form if necessary.

Start completing your Psychiatric Progress Note/Billing Form online today for seamless documentation and billing.