This template package can assist practitioners in simplifying their documentation while completing all documentation necessary for insurance purposes, but avoiding providing too much information which may compromise the privacy of your client if records are used in the court process.
 
This package includes: 
Progress Note - DAP Note FAST - Comprehensive (v2)
This note provides everything necessary to code for 90832, 90834, 90837 sessions, including add-on codes for prolonged session time 99354, 99355. 
The note provides for the multiple start and stop times available when using prolonged session codes. 
The note provides a detailed section for utilizing the add-on code 90785 for interactive complexity, including prompts to justify the use. 
The note provides a section to discuss telehealth, client consent for telehealth, and other notables related to telehealth. 
The note provides for key areas to discuss topic of session focus, interventions used in session, including additional details about three trauma-focused interventions (internal family systems, brainspotting, and EMDR), as well as a section describing how the client benefited from the interventions. 
The note provides a section assessing client's responsiveness to interventions, risk factors, including substance use relapse risk, medication compliance, and diagnostic changes. 
The note provides a section with a detailed plan for between-session tasks, when the next session will occur, and the plan for the next session. 
The final section assists in justifying medical necessity with every note.
Progress Note - DAP Note for Crisis Session
This note provides everything necessary to code for 90839 and the add-on code for prolonged session time 90840. 
The note provides for the multiple start and stop times that may be present when working with these crisis codes. 
The note prompts for a thorough MSE as required by the code.
The note assists with key words to properly document the crisis and indicate the session techniques and interventions utilized as well as client benefit.
The note prompts for a major theme of the discussion, keeping this area brief for client privacy.
Risk factors are assessed, and status of the current episode is discussed along with justification of diagnostic changes.
The final section allows for notation of the tasks that will occur between this crisis session and the next scheduled session, allows for the notation of the next appointment, and indicates the plan for the next session.