Progress notes are an essential part of the medical record and documentation required as a mental health practitioner. They provide a written description of the client's care history and are an integral part of communication amongst clinicians within the mental health sector. Not only this, but progress notes are legal documents; therefore, knowing how to write clear, accurate, and easily digestible progress notes is essential for any mental health practitioner.
The reasoning is threefold:
1. Progress notes are legal documents that provide a paper trail of a client's care history for insurance and other legal purposes. Writing progress notes after each session, ensuring the place you store them is HIPAA compliant, needs to be prioritized both for the client's safety and your protection should a worst-case scenario happen.
2. Secondly, progress notes provide a means of communication between health professionals. Daily progress notes or therapy notes provide practitioners with information on last week's content before the next session. They also act as cheat sheets or refreshers for those clinicians who have a large caseload and might struggle to remember specific details from the last therapy session.
3. Progress notes also act as a contract between the client and their mental health clinician. Treatment goals and the overall treatment plans need to be recorded so that both the client and the clinician can track the client's progress.
When writing a mental health progress note, you will find your end product far more informative and concise should you choose to utilize a format. As usual, within the health sector, there is no shortage of acronyms to choose from. I would tend to recommend the SOAP format. I find it is helpful because it is the most commonly used method for writing mental health progress notes. It is a simple and easy-to-use framework whereby you can create a therapy note that captures the most critical information in the most concise fashion.
SOAP is an acronym for Subjective, Objective, Assessment, and Plan. It is a template that will help you, as a health care provider, to write the most informative psychotherapy notes.
The subjective section of the therapy notes is where you are to gather qualitative information from the client and their point of view. Some examples of this data might include their perceived progress, things they feel they have achieved or made progress in, and places where they are struggling or need more support. This is also a place to ask about the client's goals and desires.
In this section of the SOAP notes, your role as a health care professional is to conduct some objective note-taking. In this section, you'll focus on providing the reader with a description of what occurred during the therapy session. Things you'll want to include here are; observations about your client's affect, attitude, and responses. If possible, it can also be an excellent idea to include a physical exam and vital signs.
The assessment part of the SOAP note is where you'll want to synthesize the subjective and objective sections into one easily digestible section. Using your skills as a mental health professional, you'll also want to note down your clinical impression and professional opinion on the client's progress towards their treatment goals.
In the plan section of the progress notes, you'll want to note down things that will happen in the future. When do you plan to see the client again? What do they aim to do in that time? If a safety plan is required, what is it? Are there any new goals for this individual client? This is particularly important if your client is an outpatient, as having access to a plan and goals is incredibly helpful in making progress throughout the therapeutic process.
Although the people who read your progress notes will most often include practitioners within your care team (Psychiatrists, Mental Health Nurses, Social Workers, Occupational Therapists, Psychologists, Support Workers, and Physiotherapists). There is a possibility that practitioners outside your team, the client's family members, even the client themselves could access the note. Hence, it is essential to know how to write a professional progress note that incorporates all of the necessary details and sections.
Although you might remember every detail about your client's last session, it can be easy to forget within a month or two. Therefore, notes must be specific and detailed enough to aid your memory or help other practitioners to get a good picture of your client's mental health history. It can be a good idea to explain things and avoid abbreviations not commonly used or colloquial language that might confuse the reader.
Most practitioners don't go into mental health care because they love keeping therapy notes. Despite this, you should not be practicing if you do not have a legal record of every interaction with the client. When you are short of time, it can be tempting to omit the note-taking part of your role and prioritize client-facing hours. This is a bad idea for several reasons;
1. Client safety - keeping the rest of the care team up-to-date
2. Your safety - should your competence come into question; you will have legal documentation of your actions
3. Client/practitioner relationship - if you don't keep client notes, it may be hard to remember details within the last session or goals the client wanted to achieve. Asking them to retell details or forgetting their goals will severely impact the rapport you have built with each client.
4. Workflow - Constantly avoiding writing client notes will only mean you'll have to write them at another date.
Stay up to date with your progress notes! I struggled with this until I started using voice transcription, which means no typing (I use Carepatron, which has AI-powered voice transcription. I highly recommend it- Click here to try it yourself).
As a mental health practitioner, you'll have a good understanding of how little time we have available. There's no need to write a novel for each progress note. As you get more experienced at this, you'll write concise notes that are quick to write and easy to digest. I would highly recommend using a template such as SOAP notes to ensure you get all the necessary information and help other practitioners know where to go in the note to find the details.
In summary, if you want to write a good progress note, you'll want to;
2. Be specific in your notes, include the details
3. Prioritize your notes, don't avoid doing them
5. Be brief- none of us have time to author or digest long therapy notes