Library: Policy

317:30-5-278.1. Documentation of records

Revised 6-25-09

     All psychological services will be reflected by documentation in the patient records.

• (1) All assessment, testing, and treatment services/units billed must include the following:

• (A) date;

• (B) start and stop time for each session/unit billed;

• (C) signature of the provider;

• (D) credentials of provider;

• (E) specific problem(s), goals and/or objectives addressed;

• (F) methods used to address problem(s), goals and objectives;

• (G) progress made toward goals and objectives;

• (H) patient response to the session or intervention; and

• (I) any new problem(s), goals and/or objectives identified during the session.

• (2) For each Group psychotherapy session, a separate list of participants must be maintained.

• (3) Psychological testing will be documented for each date of service performed which should include at a minimum, the objectives for testing, the tests administered, the results/conclusions and interpretation of the tests, and recommendations for treatment and/or care based on testing results and analysis.