Section 75-05-04-04 - Progress notes1. Progress notes related to the consumer's treatment plan goals and objectives must describe the consumer's progress in treatment chronologically and must document the consumer's response to services related to the treatment. 2. Progress notes must address the following: a. Activities and services provided as they relate to the goals and objective of the treatment plan, including ongoing reference to the treatment plan; b. Documentation of the progress or lack of progress made in treatment as it relates to the treatment plan; c. Documentation of the implementation of the individualized treatment plan, including consumer activities and services and all treatment rendered; d. Documentation of the consumer's response to treatment services, changes in behavior and mood, and outcome of treatment or services; and e. Plans for continuing therapy, for transfer, or for discharge, whichever is appropriate. 3. Progress notes must be documented according to the following timeframes: a. Individual and family therapy must be documented after each visit or transaction, including missed appointments; and b. Group therapy must be documented at least weekly. 4. Progress notes must include service date, signature of staff member and any professional credentials of the staff member, and the signature date. N.D. Admin Code 75-05-04-04
Effective November 1, 1987; amended effective December 1, 1991; February 1, 1996; January 1, 2009.General Authority: NDCC 50-06-05.2
Law Implemented: NDCC 50-06-05.2