The note should include a clear statement highlighting progress made towards specific treatment plan goals and objectives. For instance, instead of a vague statement like "Tom is making progress towards his goals," provide detailed evidence of progress, such as, "Tom made progress towards his treatment plan goal of managing social anxiety, as shown by two successful public outings where he practiced his new mindfulness and breathing techniques."

Specify whether the session was conducted in-person or via telehealth. If telehealth was used, mention the usage of a HIPAA-compliant audio/visual platform. For example, "I had a telehealth session with Jane where I was in my private office, and Jane was calling in by herself from her bedroom. We used a HIPAA-compliant audio/visual software [Zoom, doxy.me, SimplePractice, etc.]."

Perform and document a complete mental status examination, including at least three categories such as affect, appearance, behavior, mood, orientation, speech, thought content, and thought process. Provide specific details related to each category to paint a clearer picture. For example, "Aurora's affect was sad and her speech was flattened, but her thought process showed concrete reasoning, and her memory was sound."

Include a description of symptoms that directly support the diagnosis. Avoid generic statements and provide specific examples. For instance, instead of stating "Oscar has Generalized Anxiety Disorder," write, "Oscar's diagnosis of Generalized Anxiety Disorder is supported by the following symptoms: he reports feeling irritable, and constantly finds feelings of worry difficult to control..."

Include specific details related to the client's behavior, quotes, and observable actions. This adds depth and context to the documentation. For example, instead of writing "Sarah came into the session. She was sad," write, "Sarah said, 'I feel stressed and sad when I wake up.' She pointed out that her outfit was 3 days old and her hair was disheveled."

Clearly state the recommended frequency and level of care for future sessions, especially considering psychiatric diagnostic evaluations. For example, "Having diagnosed Antoine with Major Depressive Disorder, I have recommended he continue to see me every 2 weeks to assess progress on goals and interventions. We plan to discuss a possible referral for medication intervention."

Always include a problem statement that encompasses the initial problem or concern and the official diagnosis. For example, instead of omitting the problem and diagnosis, write, "Alyssa originally sought therapy following frequent panic attacks - at work and often in public. After diagnosing her with Social Anxiety Disorder, we have been considering some interventions to help her manage public settings."

Perform a thorough risk assessment and document any identified risk factors, following up with a corresponding safety plan if necessary. Ensure clear steps are outlined to manage risks. For example, "Tom has acknowledged a temptation to engage in self-harm. As a result, we have worked together on a safety plan to avoid further harmful actions, with the following steps:..."

Sign the therapy note with your provider signature and include your professional credentials. Ensure that this information is clear and visible. For example, "Note signed by provider - /s/ Jane Doe, Licensed Marriage and Family Therapist."

Select the appropriate CPT code that matches the duration of the session. Double-check the session length and bill the code accordingly. For example, if the session was 63 minutes long, select and designate the correct time-based CPT code (90837).