It will be important to include narrative comments related to target symptoms; goals of therapy; method of monitoring outcomes; frequency of treatment; clinical records to support relevant medical history; results of diagnostic tests or procedures; prognosis or progress to date; and, estimated duration of treatment. The types of psychotherapy recognized by CMS include psychodynamic, behavioral, and ego supportive. It is suggested to create a template that you can modify with changes that have occurred since the last session. Medicare requirements for psychotherapy session documentation are included in Box 5.1.
Box 5.1 Medicare Requirements for Psychotherapy Sessions
Gutheil, T. (1980). Paranoia and progress notes: A guide to forensically informed psychiatric recordkeeping. Hospital and Community Psychiatry, 31, 479-482.