Rule 5122-27-04 | Progress notes.
(A) A provider is to complete progress notes for each client. The progress notes are to document the degree of a client's progress toward achieving the client's treatment goals specified in the client's initial or comprehensive individualized treatment plan. This documentation may be done through brief narratives or checklists. Regardless of the form, the provider is to ensure that sufficient detail is provided in the progress notes to address all component obligations in paragraph (C) of this rule.
(B) A provider is to document progress notes each time a certifiable service or support is provided (on a "per provision of service basis"), on a daily basis, or on a weekly basis.
(C) All of the following items are to be included as progress notes documentation:
(1) The client's name or identification number;
(2) The type, description, date, time of day, duration, location and, if documenting weekly services, the frequency of treatment, with dates of service;
(3) A description of the client's current symptoms and changes in functional impairment;
(4) Changes in medications taken by or prescribed for the client, when applicable;
(5) The amount of time spent by the provider with the client;
(6) The amount of time spent by the provider in interpreting and reporting on central nervous system assessment testing codes, when applicable;
(7) An assessment of the client's progress and a brief description of the progress made, if any; significant changes in symptoms, functioning, or events in the life of the client; and a recommendation, if applicable, for modifications to the treatment plan;
(8) Evidence of clinical supervision, as needed; and
(9) The signature, date of signature, and credentials of the clinician who prepared the progress notes. The clinician who prepared the daily or weekly progress notes is to be credentialed to provide all services and supports documented in the notes.
For purposes of this paragraph, a signature may be handwritten or in any of the following forms: a code consisting of a combination of letters, numbers, characters, or symbols that is adopted or executed by an individual as that individual's electronic signature; a computer-generated signature code created for an individual; or an electronic image of an individual's handwritten signature created by using a pen computer.
(D) Progress notes are to include documentation to reflect that the certifiable service or support was provided by telehealth.
Last updated August 3, 2026 at 8:37 AM
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