Medicaid Session Note
None

 
Date of Session
 
Start Time
 
End Time
 
CPT code; 90791 diagnostic eval; 90832 16-37 min., 90834 38-52 min., 90837 53 or more min.. 90846 30 min+ family w/o cx present; 90847 30+ min family w cx present
 
Who was present
 
NOTE RELATES TO GOAL 1, 2, 3 (from treatment plan) OR case management or eval or treatment planning or other
 
Place of Service (office, telemedicine)
 
Responsible Counselor, name, degree, license #
 
Session content, treatment interventions, consistent with goals and objectives
 
Client/family response to session and level of participation (Could they list how to apply skills being taught Did they ‘not get it’, refuse to participate, resist, etc):
 
Progress toward goals of treatment plan (in emotional/behavioral terms):
 
Plan for next appointment (include date) or discharge plan.
 
Evidence of continued need, diagnosis change, or previous no-show discussion:
 

1 comment

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    Jill Lurie

    very comprehensive. thanks!

     

    very comprehensive. thanks!