Tjane Health Academy · PRP Counselor Field Toolkit

Encounter Note Template

A blank, review-ready structure for documenting a single rehabilitative contact.

Maryland telehealth and timing limits

COMAR 10.09.59.07(K) excludes group PRP telehealth and telehealth exceeding 50% of a participant's services. Verify current service-specific modality, counting, authorization, and COMAR 10.09.49 requirements before a remote visit. The reviewed PRP payment rules require documentation but did not establish a universal 24–48-hour note deadline. Follow applicable agency/payer rules; same-day writing is a recommended habit, not a verified statewide deadline.

Contact details

Participant identifier

Date of service

Start time / end time / total duration

Service location (home, community, office; telehealth only when permitted and authorized)

Service type

Goal linkage

IRP goal addressed (write the goal, not a code)

Functional need this goal serves

Intervention provided

What you observably did (modeled, rehearsed, coached, cued, accompanied, taught)

Materials or routine used

Participant response

What the participant did

Participant's own words (direct quote)

Progress or barrier

Comparison with previous baseline (counts, frequency, level of prompting)

Barrier identified, if any

Plan / next step

Next step, by when, and by whom

Coordination or notification needed

Before you sign

Intervention is tied to a written goal
Participant response includes a quote or observed action
Progress described with a count or level of prompting
Next step has a timeframe
No diagnosis, prescribing, or therapy language
No judgmental or templated wording
Times, duration, and location are accurate

Sources & review notes

COMAR 10.09.59.09 — Payment and documentation
Subsection B requires services to be delivered and documented under Department regulations for payment; F(3) conditions telehealth payment on COMAR 10.09.49. This review did not establish a universal 24- or 48-hour PRP encounter-note completion/signature deadline. Claim submission limits are different from note deadlines; applicable contracts or agency policies may be stricter.
Reviewed 2026-10-29
MDH synchronous telehealth policy guide — updated May 15, 2025
The guide linked by MDH at review states that audio-only coverage is program-specific; ordinary service restrictions and preauthorization still apply. Document participant consent (or the emergency preventing consent), use compliant technology, and maintain records as for an in-person visit. This is the guide's publication/update date, not the review date.
Reviewed 2026-10-29
COMAR 10.09.59.07(K) — PRP telehealth limitations
Excludes group PRP telehealth and telehealth comprising more than 50% of a participant's services. The rule does not define a counting period here; verify operational counting with current ASO guidance rather than inventing a monthly or annual denominator.
Reviewed 2026-10-29
Maryland Department of Health — Telehealth
General Medicaid guidance includes synchronous audio-video and audio-only care, but expressly refers to provider-specific regulations/manuals for appropriate services. General modality availability is not blanket PRP coverage; apply COMAR 10.09.49 and service-specific requirements. Historical COVID information is not a current waiver.
Reviewed 2026-10-29

Review dates record when these sources were checked, not a guarantee that requirements remain unchanged. Confirm the applicable service, payer, authorization, and agency requirements before using guidance in practice.