67 : 62 : 08 : 12 . Progress notes. A mental health staff member must record p rogress notes in the client's case record that substantiate all services provided. A mental health staff member must document the counseling sessions with the client, summarize significant events occurring, and reflect goals and problems relevant during the session , and any progress in achieving those goals and addressing the problems in the progress notes . A mental health staff member must also include attention to any co - occurring disorder as it relates to the client's mental disorder in the progress notes .

1. (1) Information identifying the client receiving services, including the client's name and unique identification number;
2. (2) The date, location, time met, the units of service of the session, and the duration of the session;
3. (3) The service activity code or the title describing the service code;
4. (4) A brief assessment of the client's functioning;
5. (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 treatment goals or objectives;
6. (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. (7) The signature and credentials of the staff providing the service.

A progress note must be included in the client's clinical record for each billable service provided. Progress notes must include the following for the services to be billed:

Source: 43 SDR 80 , effective December 5, 2016; 50 SDR 63, effective November 27, 2023 .

General Authority: SDCL 27A-5-1 .

Law Implemented: SDCL 27A-3-1 , 27A-5-1 .

Prior versions effective: 2016-12-05.