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PROGRESS NOTE TIPS

Tip #1.

It’s not unusual that multiple clients share similar CLS objectives, which means reading and utilizing different clients’ objectives may be beneficial in inspiring unique outcomes for your notes.

Tip #2.

Since progress notes MUST be handwritten, be careful, avoid white-out, and ensure writing is legible. Do not scribble, scratch out, or write side notes.

Tip #3.

Avoid single sentences & short descriptions. Be as specific as possible. Document a brief but detailed summary of services provided. Single-sentence outcomes can result in your notes being rejected.

Tip #4.

Read the CLS objectives carefully! Some clients’ objectives require a specific amount of time to be spent each day working on the objective and must be calculated correctly into the total CLS minutes.

Tip #5.

Stick to professional and approved terminology, no slang or assumptions. Use language that reflects dignity and respect.

Tip #6.

Mix it up.! Notes should be individualized each day to reflect what actually happened. Repetitive or cloned notes could lead to rejection at preview, red flags, or audit issues.

Tip #7.

The CLS objectives are a part of the client’s IPOS. Understanding and implementing them daily with the client will greatly increase your potential to write more effective and accurate progress notes.

Tip #8.

Your notes don’t need to be long, but they should clearly explain what was done,  and how it connects to the objective. Avoid filler statements like “nothing to report” if any service was delivered.

Tip #9.

Be Prompt! Submitting completed progress notes on time is crucial for ensuring that billing hours are processed accurately and that staff are paid on schedule for services provided to the client.

Tip #10.

DO YOUR OWN NOTES! The progress note process may seem tedious when first introduced, but rest assured, it gets easier; the objectives become clearer, in turn, the notes become easier to write, and hour-to-minute conversion, to align with time and date intervals, won’t seem as confusing after a few times writing them yourself.