• Introduction*
• Service Delivery*
• Progress Notes: The Narrative*
• Progress Notes – Learn More*
• Challenge*

Service Delivery

Special Note: IRTS and Residential Crisis Stabilization programs must also follow the additional requirements listed below. Day Treatment providers need to also complete a progress note daily and the note should include the interventions provided throughout the three hour treatment day.

1. On a daily basis, the residential program must:
   1. Record program attendance of the recipient.
   2. List the goal-related services in which the recipient participated.
   3. Provide rehabilitative services.
   4. Provide a recipient narrative; for example, quality of participation, observations about recipient activities, behaviors or symptoms, medication administration.
   5. Describe program case coordination activities on behalf of the recipient with family members, significant others, case managers or other providers.
2. Documentation must appear in the recipient’s record whenever the recipient’s case is discussed in team case reviews, summarizing the content of the discussion.

The case record must include the recipient’s crisis stabilization and discharge plan and clear progress notes on the outcome of goals.

All mental health rehabilitative service records must include a clearly documented rehabilitative intervention for any day a service is billed.