<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.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0 { 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.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0 { color: #000000; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000001 { color: #000000; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: bold; margin: 0; padding: 0; } span.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78000002 { color: #000000; background: white; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } span.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000003 { color: #0000FF; background: white; font-family: 'Times New Roman', 'serif'; font-size: 12pt; font-style: normal; font-weight: normal; margin: 0; padding: 0; } p.s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0-000004 { 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="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    </span><a href="https://sdlegislature.gov/Rules?Rule=67:62:08:12"><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">67</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">:</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">62</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">:</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">08</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">:</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000000">12</span></a><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000001">.  Progress notes.</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A mental health staff member must record p</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">rogress notes in the client's </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">case record that</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> substantiate all services provided. </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A mental health staff member must </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">document</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> the </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">counseling sessions with the client, summarize significant events occurring, and reflect</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">goals and problems relevant during the session</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">,</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> and any progress in achieving those goals</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">and addressing the problems</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> in the progress notes</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">. </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A mental health staff member must </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">also include attention to any co</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">-</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">occurring</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">disorder as </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">it relates</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> to the client's mental disorder</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> in the progress notes</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">.</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78000002"> </span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    A progress note </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">must</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> be included in the </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">client's clinical record</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> for each billable service provided.</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">Progress notes </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">must</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> include the following for the services to be billed:</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78000002"> </span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (1)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">Information identifying the client receiving services, including </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">the client's </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">name and</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">unique identification number;</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (2</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">)  </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">The date, location, time met, </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">the </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">units of service of the session, and the</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">duration of the session;</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (3)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">The service activity code or </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">the </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">title describing the service code;</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (4)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A brief assessment of the client's functioning;</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (5)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A description of what occurred during the session, including the specific action</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">taken or plan developed to address unresolved issues </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">for the purpose of achieving</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> treatment goals</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">or objectives;</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (6)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">A brief description of what the client and </span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">the </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">provider plan to work on during the</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">next session</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> and</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> work that may occur between sessions, if applicable; and</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    (7)</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">  </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">The signature and credentials of the staff providing the service.</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78000002"> </span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000001">Source:</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">43</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> SDR </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">80</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">, effective </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">December 5, 2016; 50 SDR 63, effective November 27, 2023</span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">.</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000001">General Authority:</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=27A-5-1"><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000003">27A-5-1</span></a><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">.</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">    </span><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000001">Law Implemented:</span><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0"> SDCL </span><a href="https://sdlegislature.gov/Statutes?Statute=27A-3-1"><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000003">27A-3-1</span></a><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">, </span><a href="https://sdlegislature.gov/Statutes?Statute=27A-5-1"><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0-000003">27A-5-1</span></a><span class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78C0">.</span></p><p dir="ltr" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78P0-000004"><span xml:space="preserve" class="s0e428b9c-f95a-4dbf-ba4f-344fd9ec5e78000002"> </span></p></div></body></html>