> ## Documentation Index
> Fetch the complete documentation index at: https://handbook.helendelovely.com/llms.txt
> Use this file to discover all available pages before exploring further.

# Documentation Standards

> What goes in the record, when, and how it protects the client, you, and the practice.

The clinical record is the legal record of care. It protects the client, it's what a payer audits, and it's what defends you if a question is ever raised. Our system is built to keep documentation short. The standards below are about it being complete and on time.

## Timing

* **Progress notes** are completed within **48 hours** of the session, and ideally the same day. Notes written days later are less accurate and, in an audit, less credible.
* **Intake assessments** are completed within **72 hours** of the intake session.
* **Treatment plans** are completed within the first three sessions and reviewed at least every 90 days, or sooner if the client's needs change.
* **Crisis and safety events** are documented the **same day**, before you leave work. See [Crisis and safety protocol](/clinical-practice/crisis-and-safety-protocol).

A session without a completed note may be held out of the production bonus count until the note is done.

## What every progress note includes

* Date, start and end time, modality (in-person or telehealth), and client location for telehealth
* Who attended
* Presenting concerns and current status, including risk when relevant
* Interventions used, tied to the treatment plan
* Client response
* Plan for next session
* Your name and credential, and your supervisor's co-signature where required

Use the practice's note template in PracticeOS. It's built to make this fast.

## What a note is not

* Not a transcript. Summarize.
* Not a place for opinions about the client's character, other people, or other providers.
* Not a place for information about third parties beyond what's clinically necessary.
* Not a place for anything you wouldn't be comfortable having the client read, because they can.

## Corrections

Never delete or alter a completed note. If something needs correcting, add an addendum, dated and signed, that references the original. Altered records are the fastest way to lose an audit and a license.

## Billing accuracy

The note supports the claim. Document the actual service and duration. Don't document a session that didn't happen, round time up, or select a code the note doesn't support. See [Billing basics for clinicians](/operations/billing-basics-for-clinicians).

## Supervision documentation

CSWs and students: your supervisor reviews and co-signs notes as your supervision contract and Utah rules require. Keep your supervision log current. See [Clinical supervision](/employment/clinical-supervision).

## Psychotherapy notes

If you keep separate process notes, keep them in the designated separate area, not in the clinical record, and keep them minimal. See [Privacy Rule and minimum necessary](/privacy-and-security/privacy-rule-and-minimum-necessary).

## Audit readiness

The practice periodically reviews a sample of notes for completeness. This is quality assurance, not surveillance. You'll get feedback, and the goal is that nothing surprises you in a payer audit.