What are they?
And why does everyone keep talking about them?
Well… as a healthcare professional, remembering details about every session can take a tremendous toll on your mental load (and health 🥴), no matter how good your memory is. Writing everything down provides an important reference point for you and ensures you can build rapport with each client by remembering essential details about each session.
So, progress notes are basically the best tool you'll have to be a great practitioner. Not to mention they're legally required in most countries.
Still confused? Not to worry.
What are progress notes?
Client notes are at the core of any health professional's practice.
They are essential documents created by the practitioner to document and maintain a client's medical records. They provide a paper trail of a client's treatment history and ensure that communication between clinicians within the healthcare sector is seamless and traceable. In addition to this progress, notes are legally required each time there is an interaction between a client and a practitioner to provide a record and ensure best practice within the practitioner community. Any competent and compliant clinician will keep a detailed set of progress notes for each client they see.
Mental health progress notes vs psychotherapy notes
Working as a mental health practitioner, you will encounter many different types of documentation. It is quite a common occurrence for providers to get confused between progress notes and psychotherapy notes. To help you avoid getting them conflated, here is an overview of the purpose and use of these two types of documentation.
Common terminologies used in mental health progress notes
Although every practitioner will have their own preference for how to write progress notes, here are some of the most commonly used terminologies that are useful to know:
Client behavior, affect, performance:
- Responding appropriately to medication
- Noncompliant with medication
- Actively listened
- Examined benefits of…
- Identified triggers
- Problem solved
- Provided feedback
- Worked on treatment plan
- Taught coping skill
Examples of individual and group therapy notes
While the general purpose of group and individual therapy notes is the same, their layout and content differs in certain ways. Essentially, all progress notes should include information regarding the patient/s current health condition and relevant details from the specific session. Where an individual note will focus on the specific client’s behaviors and responses during the session, a group note will also include information regarding the purpose of the session, the group leader’s interventions and some comments about each participant’s behaviors and responses.
Here is an example of an individual progress note, written using the SOAP format:
Date of session: 03/09/2022
Time of session: 10:03am
Patient name: Jane Smith
Subjective: Jane stated that she is “feeling better”. She has been sleeping 7-8 hours per night and has been exercising 1-2 times during the week. Jane reports being compliant with her medication and has been practicing replacing negative self-talk with positive self-talk. Feelings of worthlessness have declined.
Objective: Jane shows reduced anxiety and mild depressive symptoms. Medication compliance is good. Jane has actively included stress relieving methods into her daily life. Her affect has improved since her last session and she shows increased attentiveness and engagement.
Assessment: Jane is responding well to treatment. She is seeking practical ways to reduce her feelings of anxiety and applies these to her personal life. Compliance with medication is improving anxiety symptoms.
Plan: Jane is to continue with her current medication dosage. Meetings will continue weekly.
Here is an example of an individualized group therapy progress note:
Date of session: 10/09/2022
Time of session: 2:35pm
Patient name: Jane Smith
Group topic: The session was concerned with maintaining sobriety and drug use. Group participants were first asked to share any recent changes in their lives. They spoke about their cravings and then discussed different coping mechanisms to prevent relapsing.
Interventions by group leader: Facilitated group discussion and ensured all group members had the opportunity to speak. Led conversation away from triggering topics. Encouraged honesty and openness. Assisted with setting boundaries and identifying healthy coping mechanisms.
Individual participant’s behavior: Jane was subdued during the session. She spoke 1-2 times and didn’t offer information about her personal life. Jane admitted having cravings but denied drug use.
How can these progress note templates allow you to create effective progress notes?
Progress notes are a contract between the client and their clinician. They are where treatment goals and plans can be discussed and decided on before they are put into a document to track the treatment progression.
Without the right formula writing progress, notes can be a lengthy process. Using a format such as SOAP means that the product is far more informative and concise. SOAP is an acronym for subjective, objective, assessment, and plan. It helps ensure that each part of the therapy note has a purpose and that no critical details are missed from a progress note.
In addition to a formula such as SOAP notes, we've provided you with some templates to outline what you can expect to see ineffective progress notes… think of these templates as 'progress note goals' kinda like the Obama's are to 'relationship goals' but maybe a little easier to achieve...
Counseling progress note template & examples
For counselors, progress notes often take a journal-like form, focusing on the process between therapist and client and the counselor's own thoughts and feelings in the work. Many counselors often choose to use a SOAP (subjective, objective, assessment, plan) format as it allows for a consistent structure.
Counseling progress note example
Subjective: Tom stated that he has been feeling tired. He “isn’t sleeping well, around 3-4 hours a night”. Tom is having difficulty completing everyday tasks and isn’t socializing frequently. He states he feels “isolated and alone”.
Objective: Tom presented with a slow speech and flat affect during the session. Relationships with family and friends are reduced. Tom’s sleeping patterns are irregular. Normal food intake. Weight remains unchanged.
Assessment: Tom presented with mild depressive symptomatology. Tom was calm and adequately responsive. There are signs of mild anxiety.
Plan: Tom has another session next week at 1pm on 12/05/2022. He has a goal to reach out to a close friend and open up about how he has been feeling.
Click here to see more examples. This link includes:
- Detailed progress note examples for counselors
- Insight into what information to include in a progress note
- What the SOAP format looks like in relation to a counseling patient
If you are looking for a downloadable SOAP template, you’ve come to the right place:
Psychotherapy progress note template & examples
Psychotherapy progress notes are notes taken by mental health professionals for the purpose of documenting or analyzing the content of a conversation during a therapy session.
Psychotherapy progress note example
Subjective: Angela says her cravings for heroin have reduced to “1-2 times a day”. Angela denies use and says she has been regularly attending AA meetings. Her eating habits have improved and she is eating up to 4 meals a day. Angela expressed gratitude for improved relationships with her friends.
Objective: Angela presented as calm and attentive. She was dressed neatly and appeared well groomed. She exhibited speech that was normal in rate, volume and articulation. Mood appeared normal.
Assessment: Angela is effectively managing her sobriety. Angela shows improvement in her ability to withstand cravings.
Plan: Angela will continue weekly sessions. Next appointment is at 11am on 11/09/2022. Short term goals include exercising 1-2 times a week and increasing her part-time work hours.
Click here to see other examples. These SOAP notes can be used for:
- Creating a reusable template
- Understanding the type of information to be used in a progress note
- Psychotherapists who are looking to improve their progress notes
Looking for a psychotherapy SOAP note template? You’ve come to the right place:
Medical progress note template & examples
Medical progress notes are the part of a medical record where practitioners record details to document a patient's clinical status or progression during the course of hospitalization or over the course of outpatient care. They're a bit different.
Medical progress note example
Subjective: Sarah stated that she has had bouts of “serious chest pain” over the past 2 weeks. Sarah explained it feels like “sharp stabbing” and she experiences “breathlessness”. Sarah had never experienced a similar pain.
Objective: Sarah has had tests and labs done with no significant results. Referred to the clinic by the hospital.
Assessment: Sarah is experiencing panic attacks. Attributed feelings of intense anxiety to the recent separation from her husband.
Plan: Sarah to begin weekly sessions. Sarah was taught breathwork exercises to prevent panic attacks. When intense feelings of anxiety arise, Sarah will use 5,4,3,2,1 technique.
Click here to see further examples. This progress note examples includes:
- Information about a patient at a hypertension follow-up session
- How to create effective medical progress notes according to the SOAP format
To help streamline your clinical documentation process, we’ve created a reusable SOAP template:
Patient progress note template & examples
Patient progress notes are the component of the patient's record in which you record notes about the interaction you had with them, their reason for visiting, examinations performed on them, medications prescribed on the day, and other relevant details.
Patient progress note example
Subjective: Amy says she is feeling “more relaxed” at work. Amy has scheduled a meeting with her employer to discuss moving departments. Amy reports using calming strategies at work when she starts feeling anxious.
Objective: Amy presented as calm and attentive. Amy’s speech was normal. Amy’s mood was normal.
Assessment: Amy is responding well to the treatment plan. Her feelings of anxiety at work have decreased. Amy shows improved assertiveness in her professional life.
Plan: Amy to have a follow-up session at 10am on 3/09/2022. If symptoms have continued to improve, this will be the final session.
Click here to see further examples. This example can be used for:
- Practitioners who are documenting their patient’s progress
- Includes 15 different SOAP note examples
- Providers looking to improve their documentation skills
Sometimes the best way to guarantee consistency across documentation is to use a template. Luckily, we’ve got the perfect one for you:
Nursing progress note template & examples
Nursing progress notes are the records kept by nurses during their interactions with each client. These notes help health professionals keep track of the medications and care a patient receives and allow for the patient's medical records to be as up-to-date as possible.
Nursing progress note example using the F-DAR method:
Focus: Nausea related to anesthesia
Data: Patient complained of intense nausea. Vomited 150 ml of clear fluid at 10:00am.
Action: At 10:10am, patient given Compazine 1 mg IV.
Response: Patient reported reduced nausea at 10:45am. Patient has stopped vomiting.
Click here to see an example. This link includes:
- Information for nurses who want to use the SOAP note method
- A detailed example of a nursing progress note to provide insight for how effective documentation is structured
With the right template, streamlining nursing progress notes may be easier than you think:
Doctor progress note template & examples
Physicians record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. In addition to this, doctor's progress notes also describe the patient's condition and the treatment given or planned.
Doctor progress note example:
Subjective: Sally reports feelings of “extreme anxiety”. Referred to this clinic due to “intense chest pains”. Sally says even the smallest mishap makes her “extremely angry”.
Objective: Sally’s speech and thought content was coherent. Sally articulated her emotional states well. She exhibited anxiety symptoms when asked about her husband and children. Sally applied 5-4-3-2-1 when anxiety symptoms showed.
Assessment: Sally is experiencing significant anxiety. She is able to recognize these emotions and use grounding techniques and 5-4-3-2-1 to alleviate the symptoms. Her chest pain is caused by anxiety.
Plan: Sally to continue her weekly sessions. The next session is at 09:00am on 05/06/2022.
Click here to see another example. This doctor’s progress note example includes:
- The information that needs to be included when documenting a doctor’s session with a client
- How to format a doctor progress note, according to the SOAP format
To help ensure your documentation is consistent, accurate and effective, here is a reusable SOAP note template:
Group therapy progress note template & examples
Group therapy notes have two components. The first part of a group therapy note is the group summary. This includes basic information on the group, such as; the group name, main topic(s) covered during the session, interventions implemented, and the schedule. In the second, individualized section, it is important to document how the client engaged within the group. Include information like their level of active engagement, contributions, and reactions.
Do's and don't when writing progress notes & examples.
Here are some top tips to make sure your notes are up to scratch:
Be specific and concise in your progress notes
No one has time to write or read novels in the healthcare sector. Progress notes should be able to be easily read by other healthcare providers. You should only include relevant information and use concise language. Sentences that are overly wordy or lengthy are distracting and reduce the effectiveness of documentation.
Prioritize your notes
Letting progress notes build-up will only make the problem worse. We understand that staying on top of documentation can be difficult, especially if you see a lot of patients. Nevertheless, if you get into the habit of writing them after every session, the information you include will be much more accurate.
Use a template such as SOAP to help you
Although everyone likes to have some degree of control over their work, you shouldn’t underestimate the usefulness of templates. There are an abundance of resources available that will help you create better documentation, so use this to your advantage! Templates will also ensure that your notes are consistent, making them much easier to read for other providers.
Capture and store your progress notes on a secure practice management platform
In addition to using templates like SOAP or DAP, it is a great idea to create and store your documentation on a practice management platform. This will guarantee consistency and accessibility across your practice, leading to better coordination of care and improved clinical outcomes. Practice management systems, like Carepatron, are HIPAA-compliant, meaning the privacy of your patients is protected at all times.
Yes, voice transcription is a thing. Click here to find out how you can use it! This type of software will enable you to save significant amounts of time without compromising on the accuracy of your notes. What’s not to love?
Some common mistakes to avoid:
In the assessment section, do not rewrite what you stated in the subjective or objective sections. Some practitioners find it difficult to differentiate between the sections of a progress note, but it’s important that you don’t repeat yourself. Every sentence that you write should be conveying new information, and you should keep this brief and concise.
Writing too many notes in the session
Although it can be tempting to write down notes during your session, it is essential that you give your client all of your attention. You want to ensure that your patient feels like their needs are being listened to and it’s your responsibility to deliver this level of professionalism. Feel free to capture some brief notes as you go, but the majority of your documentation should be completed after your session.
Ensure you use professional language in your notes. All of the information that you write pertaining to the client’s behavior or attitude needs to be supported by evidence. Remember that progress notes can be used in insurance and legal situations and they are frequently shared between providers - so including any type of biased judgment is an absolute no-go.
Avoid acronyms and abbreviations
Considering the likelihood of your progress notes being shared amongst other providers, insurance teams and even legal staff, it's best to minimize acronyms and abbreviations to prevent misinterpretation.