Instruction
A) Client description: 1-2 sentences in length.
B) Includes all relevant subjective and objective data necessary for differentiation of the client’s problem using the OLDCART and/or SIGECAPS Mnemonics.
C) Assessment: Includes progress note- 5 or more sentences
D) Homework: 2-3 sentences and plan for next session.
E) Needs for follow up
F) Diagnosis: current and rule-out; ICD code that is applicable and appropriate for session.
G) CPT code that is applicable for session
*Psychotherapy note must incorporate at least four evidence-based practice articles