How to Establish Clinical Necessity in Your Progress Notes
Ensuring that progress notes demonstrate clinical necessity is vital for ethical documentation, insurance reimbursement, and continuity of care. One effective way to document clinical necessity is through the SOAP note format, which structures notes systematically: Subjective, Objective, Assessment, and Plan. This article outlines how to integrate clinical necessity into each component of SOAP notes.
Client Vignette
You have been working with a female client (42), who presented with high anxiety and depressive symptoms, which negatively impacted her relationships at home and work to a degree she no longer felt she can successfully manage. After your initial assessment and confirmation of the relevant symptoms, you established a F43.10 (Post-traumatic stress disorder, unspecified) diagnosis, based on the client’s base line measures (GAD-7, PHQ-9, PCL-5, ACES, AUDIT) and her trauma history. You developed a treatment plan with the client to focus on reducing the anxiety and depressive symptoms while processing her trauma to alleviate her triggers leading to such symptoms.
In today’s session, your client shared having had a difficult week during which she felt criticized at work during a team meeting, leaving her worried about her job security. Simultaneously, her heightened anxiety about work led to several arguments with her husband at home, who she felt did not empathize with her situation and instead blamed her for being too sensitive. As a results, your client is worried about the her relationship with her husband, which she noted put her in a depressed mood with difficulties to sleep through the night.
S: Subjective
The subjective section captures the client’s reported experiences, concerns, and symptoms. To establish clinical necessity, ensure that:
The client's statements reflect a clinically significant concern (e.g., distress, impairment, or functional limitation).
The client’s concerns are directly related to treatment goals.
You document quotes or summaries that align with DSM-5 diagnostic criteria when applicable.
You note what interventions were used during the course of the session and how the client responded to those interventions.
You recognize what treatment goals were addressed throughout the session.
Example
You have been working with a female client (36) with high anxiety and depression
Client reports, "I have been feeling extremely anxious, and it’s getting harder to leave the house. I skipped work twice this week because of panic attacks."
This statement demonstrates functional impairment (missing work) and justifies continued treatment.
O: Objective
The objective section includes observable data, assessments, and clinician observations. This section should:
Document measurable behavioral, cognitive, or emotional symptoms.
Include mental status exam findings (e.g., affect, speech, thought process).
Use standardized measures or symptom scales when applicable.
Example:
Affect: Anxious, fidgeting, avoiding eye contact.
Speech: Pressured at times.
PHQ-9 Score: 16 (moderate depression).
This objective data supports the clinical necessity of continued treatment.
A: Assessment
The assessment section interprets the subjective and objective data, making it clear why treatment is needed. To establish necessity:
Link symptoms to a clinical diagnosis.
Discuss the impact on daily functioning.
Show the client’s response to treatment and the need for ongoing care.
Example:
The client meets criteria for Generalized Anxiety Disorder (GAD) per DSM-5, experiencing excessive worry and panic attacks leading to occupational impairment. Symptoms persist despite implementing initial coping strategies. Therapy is necessary to develop further emotion regulation skills.
P: Plan
The plan outlines the next steps in treatment and ensures documentation justifies continued care. It should:
Specify the treatment approach (e.g., CBT, EMDR, IFS).
Include measurable goals.
Address modifications to treatment if previous interventions were ineffective.
Example:
Continue weekly CBT sessions focusing on exposure therapy and cognitive restructuring to reduce avoidance behaviors. Assign relaxation techniques for daily practice. Client will track panic episodes in a journal for review in the next session.
Final Thoughts
To ensure clinical necessity is well-documented in progress notes:
Tie symptoms to diagnoses and impairments.
Use clear, objective language.
Show that treatment is ongoing, necessary, and targeted toward measurable goals.
By integrating these elements into SOAP notes, clinicians can produce strong, defensible documentation that supports client care and meets regulatory and reimbursement requirements.
