South Dakota Administrative Rules
Title 67 - Department of Social Services
Article 67:61 - Substance Use Disorders
Chapter 67:61:07 - Clinical processes
Section 67:61:07:08 - Progress notes
Current through Register Vol. 50, page 114, March 25, 2024
At least one progress note must be recorded in a client's file each week when services are provided for all programs, except for prevention programs.
Progress notes must be included in the client's file and substantiate all services provided. Progress notes must document counseling sessions with the client, summarize significant events occurring, reflect goals and problems relevant during the session, and reflect any progress in achieving those goals and addressing the problems. Progress notes must include attention to any co-occurring disorder, as it relates to the client's substance use disorder.
A progress note must be included in the file for each billable service provided. Progress notes must include the following for the services to be billed:
(1) Information identifying the client receiving the services, including the client's name and unique identification number;
(2) The date, location, time met, units of service of the counseling session, and the duration of the session;
(3) The service activity code or the title describing the service code, or both;
(4) A brief assessment of the client's functioning;
(5) A description of what occurred during the session, including the specific action taken or plan developed to address unresolved issues for the purpose of achieving identified treatment goals or objectives;
(6) A brief description of what the client and the provider plan to work on during the next session and work that may occur between sessions, if applicable; and
(7) The signature and credentials of the staff providing the service.
General Authority: SDCL 1-36-25, 34-20A-27.
Law Implemented: SDCL 1-36-25, 34-20A-27(3)(4)(6).
