Which item is NOT typically included in a progress note?

Which item is NOT typically included in a progress note?

• A. Billing code
• B. Therapist observations
• C. Interventions used
• D. Artwork produced

Answer: (A)

Progress notes focus on the clinical content of a session—what happened, how the client responded, and how treatment progressed. This includes the therapist’s observations about the client’s mood, behavior, engagement, and shifts in functioning; the specific interventions or techniques used during the session; and material the client produced or expressed during art therapy, such as artwork, which helps illustrate the therapeutic process and any changes toward goals. Billing codes, on the other hand, are administrative details used for reimbursement and are typically found in separate billing documents rather than the clinical progress note. So the item not typically included in a progress note is the billing code.

Progress notes focus on the clinical content of a session—what happened, how the client responded, and how treatment progressed. This includes the therapist’s observations about the client’s mood, behavior, engagement, and shifts in functioning; the specific interventions or techniques used during the session; and material the client produced or expressed during art therapy, such as artwork, which helps illustrate the therapeutic process and any changes toward goals. Billing codes, on the other hand, are administrative details used for reimbursement and are typically found in separate billing documents rather than the clinical progress note. So the item not typically included in a progress note is the billing code.