<html xmlns="http://www.w3.org/1999/xhtml"><head><meta charset="UTF-8" /><title></title><meta name="Generator" content="PowerTools for Open XML" /><style>span { white-space: pre-wrap; } p.sa087aeed-1832-43ba-b262-b1efd7437fbcP0 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: Calibri; font-size: 12pt; line-height: 108%; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000001 { background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000002 { background: #FFFFFF; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000003 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: Calibri; font-size: 11pt; line-height: 108%; } span.sa087aeed-1832-43ba-b262-b1efd7437fbc000004 { background: white; font-size: 11pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005 { margin-top: 0; margin-bottom: 0; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: justify; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; line-height: 108%; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000006 { background: white; font-family: Calibri; font-size: 11pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa087aeed-1832-43ba-b262-b1efd7437fbc000007 { background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000008 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000009 { margin-top: 0; line-height: 115.0%; margin-bottom: 10pt; margin-left: 0; margin-right: 0; text-indent: 0.00in; text-align: left; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; } </style></head><body><div><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:61:07:08"><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">67</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">:</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">61</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">:</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">07</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">:</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000000">08</span></a><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000001">.  Progress notes.</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> The direct care provider must record at least one progress note in the client</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000002">'</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">s clinical record each week when services are provided for any program, other than a prevention program</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000003"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbc000004"> </span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000006">    </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">Progress notes </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">must be</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> included</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">in the client's </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">clinical record</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> and substantiate all services provided. </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">P</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">rogress notes </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">must </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">document counseling sessions with the client, summarize significant events,</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">reflect goals and problems relevant </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">to</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> the session</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">,</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> and </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">reflect </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">any progress in achieving</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">those goals and addressing the problems. Progress notes </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">must</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> include attention to any co</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">-</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">occurring</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">disorder</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">,</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> as </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">it</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> relate</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">s</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> to the client's substance use disorder.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbc000007"> </span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    A progress note </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">must be</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> included in the </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">client's clinical record</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> for each billable service provided. </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">In order for a service to be billed, the progress note must contain</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">:</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbc000007"> </span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (1)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">Information identifying the client receiving</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> the</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> service, including</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> the client's</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> name and</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">unique identification number;</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (2)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">The date, location, time met, </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">the </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">units of service of the counseling session, and the</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">duration of the session;</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (3)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">The service activity code or </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">the </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">title describing the service code;</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (4)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">A brief assessment of the client's functioning;</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (5)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">A description of what occurred during the session, including the specific action</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">taken or plan developed to address unresolved issues </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">for the purpose of achieving</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> identified treatment goals</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">or objectives;</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (6)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">A brief description of what the client and </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">the clinician</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> plan to work on during the</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">next session, </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">and</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> work that may occur between sessions, if applicable; and</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    (7)</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">  </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">The signature and credentials of the staff providing the service.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbc000007"> </span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000001">Source:</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">43</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> SDR </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">80</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">, effective </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">December 5, 2016</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">; 46 SDR 50, effective October 10, 2019</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">; 50 SDR 63, effective November 27, 2023</span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000001">General Authority:</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=1-36-25"><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000008">1-36-25</span></a><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">, </span><a href="https://sdlegislature.gov/Statutes?Statute=34-20A-27"><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000008">34-20A-27</span></a><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000005"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">    </span><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000001">Law Implemented:</span><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=34-20A-27"><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0-000008">34-20A-27</span></a><span class="sa087aeed-1832-43ba-b262-b1efd7437fbcC0">.</span></p><p dir="ltr" class="sa087aeed-1832-43ba-b262-b1efd7437fbcP0-000009"><span xml:space="preserve" class="sa087aeed-1832-43ba-b262-b1efd7437fbc000007"> </span></p></div></body></html>