15 actionable tips to write professional progress notes (2023)

Katherine Ellison
Katherine Ellison
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How to Write a Good Progress Note 

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 are essential for any mental health practitioner. 

Why are Progress Notes so Important? 

The reasoning is threefold: 

Legal documents 

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. 

Means of communication

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. 

A contract between clients and clinicians 

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.

What format do I use? 

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? What does that stand for? 

SOAP is an acronym for Subjective, Objective, Assessment, and Plan. It is a template that will help you, as a healthcare provider, to write the most informative psychotherapy notes

Subjective 

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. 

Objective 

In this section of the SOAP notes, your role as a healthcare 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. 

Assessment 

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. 

Plan 

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 between sessions? 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, and 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.

Progress note template feedback

Essential Components of a Good Progress Note 

Date and time: Every single progress note that you write needs the date and time of the session. This information is necessary for tracking patient progress so even if you don’t write your progress notes immediately after an appointment, you need to ensure you have the right information recorded.

Accurate patient information: Patient demographic information is included in progress notes. In order for your notes to be effective (particularly when it comes to coordination of care), this information needs to be accurate.

Subjective review of the patient: The subjective section of a progress note should be around 3-5 sentences long. Although it is based on the patient’s opinion, you should encourage them to explain why they feel the way they do. 

Include any lab or test results: Every test result needs to be recorded, even if it seems somewhat trivial.  

Record any unusual details: If something out of the ordinary occurs during a session (and this could be as simple as the patient saying something unusual), it is a good idea to record it. Progress notes are used to develop a thorough understanding of a patient’s health status, as well as being a form of legal evidence, so it’s always a good idea to record as many pertinent details as you deem necessary. 

A specific plan: A progress note plan isn’t helpful unless it is specific. You should include the date and time of your next session and the specific, measurable goals/intervention methods that the patient has set.

We acknowledge that every progress note will vary slightly depending on the patient you are seeing and how far through a treatment program they are, but these are some of our top tips to help create effective progress notes. 

15 Actionable Tips to Write Professional Progress Notes 

Be Specific 

Although you might remember every detail of 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. 

Prioritize Your Notes 

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, including client safety, your own protection, the relationships you have with patients, and the general workflow at your practice.

Be Brief

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. 

Use a Template 

I would highly recommend using a template such as SOAP notes to ensure you get all the necessary information and other practitioners can easily find the details they are looking for. 

Voice Transcription 

One of the best ways to write accurate and efficient progress notes is through voice transcription software. This will save you significant amounts of time without compromising the accuracy of the documentation. 

Legibility

This may seem like an obvious point, but it is extremely important that your progress notes are legible, particularly given how frequently they are shared between other providers. In order to guarantee legibility, we would recommend using an online documentation platform, but if you are determined to handwrite yours then you need to keep your writing neat and readable.

Professionality 

Although there are some cases where your opinion, as the patient’s provider, is necessary to include in a progress note, you need to ensure you remain professional at all times. 

Follow the Right Mistake Protocol

Making an error while writing progress notes is inevitable, but it’s essential that you follow the right protocol when this happens. Don’t delete or cover up the mistake - instead, simply draw a line through it and record the date and your signature. 

Avoid Acronyms 

Although certain universally understood acronyms can be included within a progress note, if you’re unsure whether they will be understood it is a good idea to simply avoid them. This way, your notes will be accessible and easily comprehended by other providers.

Writing More Than One Page

If your progress note extends past one page, you need to acknowledge this. By writing something like “Continues onto the next page”, you can ensure no one misses any important information when they are reviewing the documentation. 

Know Your Codes

Progress notes include codes that indicate the treatment methods and possible diagnoses. After a bit of practice, it is highly likely that you will know many of these codes, but it is nevertheless always a good idea to double-check you have recorded them correctly. 

Timeliness

We cannot overstate the importance of writing progress notes whilst the information is still fresh in your mind. Letting your documentation pile up can lead to inaccurate or missed details, which can have a severe impact on your patients. 

Repetition is key 

Getting into the habit of writing good progress notes will help simplify the documentation process immensely. You should dedicate a certain amount of time every day (or every couple of days), and diligently write your progress notes. After a while, this will become routine and you will find yourself making fewer errors and producing higher quality notes.

Keep Your Client in Mind

When writing your notes, you should keep your client in mind. Every client is different, and you may find it more applicable to use alternative templates for your patients, depending on their treatment plans. 

Be Factual

Despite the need for some subjective information, this should always be based on fact. Record what you saw, heard, or did, rather than your personal opinion about these facts.

Good vs Bad Progress Notes 

A lot of the time it can help to see specific examples of what a progress note should (and shouldn't) look like. As such, we’ve included some excerpts from good and bad progress notes that will hopefully clarify your knowledge. 

Bad example:

Thomas had a fever during his session. 

Good example:

At 4:15 pm Thomas’s temperature was recorded as 39 degrees. 

Bad example:

James seemed tired during the session. He was irritable and didn’t look like he had showered recently. 

Good example:

James said he was having difficulty sleeping. He was unfocused during the session and struggled to respond to my prompts and questions. He was wearing clothes that had visible stains on them. 

Bad example: 

Samatha was difficult to deal with. She wouldn’t answer my questions and said these sessions were stupid. This week her teacher told her parents who relayed to me that she is angry in class and doesn’t have many friends.

Good example:

Samantha exhibited disinterest and frustration during the session, saying “these sessions are stupid”, and struggled to vocalize responses. Samantha’s teacher reported she exhibits angry behaviors in the classroom and has difficulty socializing.

Bad example:

Amy is highly anxious and has been recently abusing drugs.

Good example:

Amy reported feeling “extremely anxious”. She found it difficult to sit still during the session and rocked back and forth on her chair. Amy has been using injection drugs “at least every two days”. 

Bad example:

Peter will work on stopping his negative self-talk. 

Good example:

Peter will practice replacing negative self-talk with positive self-talk over the next week. 

Although these are only excerpts from potential progress notes, you will have hopefully observed the issues in the “bad examples”. Some of these have judgemental and opinionated language, some aren’t concise enough and others are too brief. Whilst there are a number of different ways you can approach writing progress notes, these hopefully provide some insight into the type of information to include.

Steps to Writing Effective Progress Notes 

Although each healthcare practitioner will have their own methods for writing progress notes, we’ve created some brief steps for you to follow to ensure they are completed accurately and efficiently. 

  1. Get into the habit of writing your notes at the end of every work day.
  2. Use an online system so the process is faster. 
  3. If you handwrite, use a black pen and ensure your handwriting is legible.
  4. Sign, time, and date the entry.
  5. Always check that you are writing in the relevant client’s notes.
  6. Double-check spelling. 
  7. Avoid acronyms and abbreviations.
  8. Be specific about what happened during the session. Avoid opinions and instead clearly state facts.  
  9. Record the details of any unusual event.
  10. Include a detailed future plan, including the time and date of the future session where applicable, and what the client will be working on between sessions.

Common Terminologies and Interventions Used in Progress Notes 

To help make the process of writing documentation easier for you, here’s a list of common terminologies:

Developing coping strategies: Refers to skills and strategies taught to clients to help them manage difficult situations. 

Goal review: Discuss the client’s progression towards their goals.

Problem-solving skills: Specific skills that a client can use to solve day-to-day problems they experience.

Communication training: A method used to teach clients how to communicate with others more effectively. 

Behavior reinforcement: When a behavior is either positively or negatively reinforced in an effort to increase or decrease the behavior being repeated.

Other common words:

  • Actively listened
  • Assigned task 
  • Appeared attentive/engaged/interested
  • Appeared inattentive/disinterested/unfocused
  • Building trust
  • Clarified
  • Encouraged
  • Established boundaries 
  • Identified awareness of
  • Processed
  • Positively affirmed
  • Reinforced
  • Reflected
  • Verbalized 

Don’t sleep on your progress note for another second, sign up for Carepatron for free to focus more on the people who need you most. 💜

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