Introduction to progress notes
Progress notes are one of the most fundamental aspects of working as a healthcare professional. Together with other records, they make up clinical documentation; a collection of information that tracks a patient’s experience within the healthcare system.
What is a progress note?
Progress notes are pretty self-explanatory; they are designed to track and monitor the progress of a patient. In saying that, there are a number of additional applications of progress notes that make them extremely important documents for practitioners to master. And this is where we can help. In this guide, we’ll break down for you the basics: including what progress notes are used for, who writes them, what information they need to include, and various examples and templates. Once you’ve finished reading, we guarantee you will be equipped with the knowledge required to produce the perfect progress note and improve the quality of healthcare delivered to patients in need.
What is the purpose of a progress note?
Before we begin to explain the contents of a progress note, we need to touch on why they are important. And whilst that might not sound very interesting, it poses various implications for practitioners, so is a topic you should be well versed in.
Firstly, as we mentioned briefly, progress notes are used to track the progress of clients. After a patient has their first appointment with a practitioner, this encounter is recorded by the provider and stored. If the patient returns for a second, third, or fourth appointment, the details of these sessions are also documented. When the practitioner wants to review the progress of their patient, they need only look at the progress note and they will be able to identify the improvements or changes noted in the patient’s health.
Secondly, progress notes are frequently used to facilitate effective inter-provider communication. Why is that important? Because patients are often transferred between departments and facilities during their time in the healthcare system, up-to-date information regarding their condition needs to be conveyed between all primary providers. If communication is absent or ineffective, the health of the patient is at risk. Treatment and medication decisions are reliant upon the fact that providers are fully informed about a patient’s health status, and progress notes are the perfect way to ensure this is the case.
Thirdly, occasionally there will be an instance where a patient is unsatisfied with the treatment they have received at a healthcare practice and they will get lawyers involved. Whether it is a malpractice suit or an investigation into the treatment decisions made by a practitioner, it is essential that you have protocols in place that can demonstrate the reasoning behind your decisions. And this is where progress notes come into play. They outline each encounter with a patient, including the patient’s symptoms and diagnosis, and the practitioner’s treatment decisions are backed up by relevant evidence. Progress notes shouldn’t be completed with the sole aim of protecting against these scenarios, but they do have the ability to serve as legal evidence.
Lastly, progress notes are also often shared between insurance companies during the medical billing process. In order for a practice to receive reimbursement for their services, they need to have very specific documentation. Progress notes can be used by coders to create codes, which are translated into a claim and sent to the insurance company. Once at the insurance company, the codes may need to be verified and progress notes (and other forms of clinical documentation) might be requested.
So, to summarize, there are four main purposes of progress notes:
- To track a patient’s progress
- To communicate between providers
- To protect a practitioner and their practice
- Insurance
Failure to produce effective and accurate progress notes, therefore, has many implications for both practitioners and patients, a situation you no doubt want to avoid. On the other hand, good progress notes help ensure that a patient is receiving the right kind of treatment, improves communication, can serve as legal protection, and guarantees a practice receives reimbursement for their services.
Difference between progress notes and psychotherapy notes
Before we dive deeper into the contents of progress notes and how they are written, it is first necessary to distinguish between them and psychotherapy notes. Understanding the key differences between forms of clinical documentation can be confusing, and a lot of the time these two documents are conflated. Whilst progress notes and psychotherapy notes are both records kept by healthcare providers, they serve entirely different purposes:
Progress Notes
- Written by any healthcare practitioner.
- Content includes subjective and objective notes regarding the patient, their treatment plan, and any observable progress.
- Progress notes can be shared between other healthcare practitioners and used in legal situations or by insurers.
- Progress notes need to be HIPAA-compliant.
Psychotherapy Notes
- Written by psychologists, psychiatrists, counselors, and psychotherapists.
- Content includes information regarding the practitioner’s opinions, thoughts, and hypotheses on the patient. Psychotherapy notes do not include information on diagnoses or past medical treatment.
- These notes are kept private from the patient and other care providers.
- Psychotherapy notes need to be HIPAA-compliant.
Who writes progress notes?
You might be wondering whose exact responsibility it is to write progress notes, and you may be surprised to know, that it’s any healthcare professional who sees patients. Different professions and practices will have their own protocols regarding how clinical documentation is written, but it is always a healthcare provider's responsibility to ensure that their encounters with a patient have been properly documented. The popular saying, “If it isn’t documented, then it didn’t happen” is applicable to almost all healthcare professions, including:
- General practitioners
- Nursing
- Psychology
- Psychiatry
- Physiotherapy
- Counseling
- Mental health therapy
- Occupational therapy
- Chiropractor
- Psychotherapy
- Physical therapy
- Aged care
- Nutrition
What should be included in a progress note?
Now that you know what a progress note is, and whether you are required to write them, it is time to move on to its contents. Whilst the specific information that is included within progress notes (and every form of clinical documentation) will depend on your profession and the appointment with your patient, there are certain universals that you should be aware of.
Background information: Every progress note needs to include the names of the patient and the practitioner, in addition to the details of the session, including date and length of time.
Diagnosis: If relevant, the ICD-10 or DSM-5 codes of the patient’s diagnosed condition, or the practitioner’s professional opinion on the potential diagnosis of the patient.
Patient information: Observational information regarding how the patient has presented themselves, including their behaviors, attitudes, and affect.
Symptoms: Descriptions of the symptoms that the patient is experiencing and how they have impacted the patient’s day-to-day life. If this isn’t the first session with a patient, then include whether these symptoms have improved or changed since the previous session.
Test and assessment results: Include the results from any relevant tests or assessments that the patient has completed during the session. This could be neurological scans, mood scales, or physical tests.
Treatment and future plan: The provider should discuss whether the intervention that the patient has been subjected to has led to any notable changes. The treatment plan may need to be modified, and new goals formed for the patient. The practitioner should include the date and time of the next session.
Signatures: All progress notes are signed by the practitioner and stored in a secure, HIPAA-compliant manner.
This may seem like an exhausting list of things to include, but once you get into the habit of writing progress notes, remembering these details will become much easier. There are also various tools that can help ensure you are covering all bases, including note templates and software. Before we get into these, we want to quickly touch on an important detail: the time frame during which you write your notes.
When should you write progress notes?
As I’m sure you know, different practitioners will have their preferences for how to complete the required work. While we are not here to tell you to change a system that works perfectly well for you, there are certain challenges you should be aware of. Firstly, it isn’t a great idea to write your progress notes during a session. Your patient may feel as though you aren’t paying them much attention, and you might be getting too distracted to properly deliver a high-level quality of care. Alternatively, if you leave it too late after the session, there is a high likelihood you will forget some of the important details. Further, it is detrimental to your own workflow if you let your paperwork stack up. Imagine you have worked a long, 40-hour week and when you get to Friday afternoon, you realize you have 15 appointments to document; an unfortunate and completely avoidable scenario.
Our solution to this situation is to suggest for practitioners to write their progress notes either immediately following a session with a patient, or at the end of each working day. This way, you will ensure that your patient's needs have been met, you are staying on top of your paperwork, and your notes contain as much relevant detail as possible.
Tips to writing good progress notes
You now know what a progress note should include, and whilst this is undoubtedly important information, it probably isn’t enough to guarantee the production of highly effective notes. So what exactly can you do to make sure your notes are as good as they can possibly be? Luckily, we’ve done our research into this: we’ve read copy after copy of progress notes and extracted the key elements that are indicative of a great document. You may have your own system of writing notes and this is perfectly fine, but we recommend bearing in mind the following strategies when completing your documentation:
Objective: Whilst some subjectivity is necessary within progress notes, including the practitioner’s professional opinion of the patient’s presentation, objectivity should always be prioritized. Any opinions or judgments included within the note need to be backed up by supporting evidence, and it is important that practitioners avoid using language that has negative connotations attached.
Thorough but concise: You may be looking at the list we provided of the different topics to include in a progress note and wondering how you’re supposed to keep it concise, but we cannot emphasize this point enough. Progress notes are frequently shared between various third parties and other providers, who need to be able to quickly scan the document and extract relevant information. Each sentence you include should contain important information and you need to avoid using vague or repetitive language. Although the specific length of a clinical document isn’t strictly determined, it is a good rule of thumb for progress notes to never exceed two pages in length.
Relevant information: When practitioners write their progress notes, it can be easy to get somewhat carried away and include information that isn’t directly relevant to the topic at hand. Not every single conversation that happened during the session needs to be recorded; the practitioner should be focusing on the information that indicates the patient’s progress or condition. Whilst writing your progress note, it is a good idea to continuously ask yourself whether the information provided is both necessary and relevant. If it isn’t, remove it.
Legible: This may seem incredibly obvious, yet legibility is something we felt inclined to include given the number of progress notes that are illegible. If you choose to hand-write your progress notes, your writing needs to be neat and clearly structured. Bad handwriting prevents third parties and other providers from being able to use your notes properly, leading to poor communication and worse treatment decisions. We’re going to discuss the different options for clinical note software soon, but it is important to know that handwriting notes isn’t your only option. In fact, if you are someone who has messy writing, then we highly recommend moving away from manual production and implementing electronic note-taking means.
Accessible: Given how frequently progress notes and other forms of clinical documentation are shared between third parties and other healthcare providers, it is extremely important that they are accessible. As such, is only step one in ensuring effective clinical documentation; storage also has a significant role to play. Most healthcare practices have implemented EHR (electronic health record) systems to improve their accessibility as this type of electronic software allows authorized users to access the database at any given time.
Things to avoid when writing progress notes
We’ve covered some of the top strategies that will help you produce effective progress notes, and now it’s time to look at what you should be avoiding. Although making mistakes is an inevitable part of learning any new skill, it is worthwhile having an awareness of some of the most commonly made errors when writing progress notes. Furthermore, there is an incredibly high number of errors that are reported by patients who view their medical records and clinical notes. A study published by the Journal of the American Medical Association reported that one-fifth of patients who read their notes found a mistake, which is a statistic that should be significantly reduced. Mistakes in progress notes lead to ineffective communication between healthcare providers, the possibility of wrong treatment decisions, and consequently worse clinical outcomes. We’ve done our research and compiled a list of some of the most common (and avoidable) mistakes that are made when writing progress notes:
Notes not dated: Forgetting or failing to include the date of the session and the date that the progress note was created is an incredibly common mistake made. Given the role that progress notes can play in insurance and legal contexts, it is absolutely critical that they are correctly signed and dated. After a practitioner has completed writing the note, they should double-check that these details are correct, otherwise, it may not be able to be used in certain situations.
Incorrect mistake procedure: When you are writing a progress note and you make a mistake, there is a specific procedure that you are required to follow. The mistake needs to have a single line through it (so it is still readable) and it needs to be dated and signed with initials. This way, whoever reads the progress note is able to verify the authenticity of the information included.
Jargon: As a healthcare professional, there are various medical terms and jargon that are used to describe patient symptoms, treatments, and conditions. However, it is important that these aren’t used in progress notes. As you know, progress notes are shared between various third parties, including people outside of the medical profession. As such, the information included within clinical documentation needs to be able to be understood universally, regardless of an individual’s experience in the healthcare system. It is best to avoid using any type of medical-specific jargon, and when including abbreviations, ensure that they are universally understood.
Assumptions and general statements: We briefly mentioned earlier the importance of staying objective when it comes to writing progress notes. However, there will undoubtedly be certain situations in which a professional opinion or subjective statement is required, and when this is the case, it is important that these comments are supported by evidence. The most important two things to avoid are assumptions and general statements. Both of these are unreliable and fail to provide meaningful insight into the patient’s progress and current health status.
Shortcuts and shorthand: It can be tempting for practitioners to use shortcuts when it comes to writing clinical documentation, particularly if they have a large stack of notes to complete at the end of a day. However, we cannot stress enough how problematic these shortcuts can be. If you choose to use an electronic system to write your progress notes, many of these allow you to copy and paste or insert commonly used terms and phrases. Whilst this can be helpful when it comes to minor details, it is important that you keep it to a minimum. Relying on shortcuts opens up the possibility of inaccurate or false information, which can consequently damage a patient’s treatment outcome.
Illegible: We spoke before about the importance of legibility when it comes to writing progress notes, especially given how frequently they are shared between third parties. If you have messy handwriting, then you should definitely look into using an electronic system. Illegible progress notes make effective communication extremely difficult, which is one of the target goals of clinical documentation.
Phone calls: As an increased number of healthcare practices are implementing telehealth features, including remote sessions, it is becoming harder to keep track of what encounters require documentation. However, as the saying, “if it is not documented, then it didn't happen” indicates, every single encounter, including phone calls and remote appointments, needs to be documented. If you are unsure about whether or not to document something, you can always check with a supervisor or manager. Further, documenting something can never do any harm and it is much better to have extra records than a gap in the documentation.
A quick note on compliance
Just like any other area of healthcare, compliance has a role to play in ensuring that progress notes are created, stored, and shared in the right way. HIPAA (the Health Insurance Portability and Accountability Act) sets out guidelines that protect certain information within a progress note, including personal identifiers of the patient and details of the patient’s medical history and current treatment. If the provider wishes to share any of that information, they are required to obtain the patient’s direct authorization.
However, whilst this is the general rule, there are certain exceptions. If there is a situation where either the patient or the public is at risk of harm, the provider does not need the authorization to disclose their progress notes. Further, if a patient requests to access their progress notes, then their healthcare provider is required to grant it to them. For this reason, it is important that the progress notes are entirely professional and contain relevant and objective information.
In regards to the creation of progress notes, HIPAA dictates that healthcare practices are required to educate and train their employees to comply with the relevant regulations and protocols. In the case of a breach of HIPAA guidelines, then the practice is required to investigate the claim thoroughly and discipline the staff members responsible for the breach. We won’t go into too much detail here of the consequences of HIPAA breaches, but they can range between minor USD $500 fines up to $1.5 million fines, losing a license, and jail time. In addition to the damage this does to a healthcare practice’s financial condition, HIPAA breaches can negatively impact reputation and lead to a loss in clients. Avoiding these situations should be a top priority of all healthcare practices, so staying aware of current compliance regulations is in your best interest.
Once progress notes have been completed, they need to be securely stored and protected against any unauthorized access. Progress notes often contain highly confidential information, including personal details regarding a patient and their medical records. It is the healthcare provider’s responsibility to ensure that this information isn’t jeopardized in any way. Although different practices will have their own methods of storing and securing progress notes, we would recommend electronic storage over manual. Paper copies of progress notes are at much greater risk of being lost, stolen, or damaged, and recovering these is extremely difficult. Alternatively, electronic copies can be stored on remote servers where they are encrypted, and protected by various security measures.
If you decide to write and store your progress notes using electronic methods, they are considered to be EPHI (electronic protected health information), and come under the protection of the Security Rule. The Security Rule dictates that specific safeguards need to be in place in order to protect data stored online:
- Administrative safeguards
- Technical safeguards
- Physical safeguards
It is important to understand that regardless of the specific security measures that your practice has in place, any type of confidential data will always be at some sort of risk. Nevertheless, if you use electronic storage methods for your progress notes and utilize the above safeguards in addition to various security measures, then there is a very high chance your data will be protected against unwanted access.
Understanding all of the different regulations and protocols that impact how clinical documentation is created and stored can take a long time, but this is a process that is highly necessary. We have only briefly touched on how these protocols relate to progress notes, and would highly recommend you do further research. Feel free to have a look at the following links, each of which contains useful information regarding compliance:
- Guide to Privacy and Security of Electronic Health Information: This is a basic overview of HIPAA guidelines. The website has links to training games and risk assessment tools.
- State Attorneys General: A more comprehensive overview of what HIPAA and HITECH entail.
- CMS HIPAA Basics for Providers: Details of the role that providers play in adhering to HIPAA compliance, with additional information on how the breach notification rules and possible consequences of non-compliance.
- World Health Organization: Catalog of resources to support health services delivery transformations.
Different progress note templates
A benefit that has arisen out of the importance placed on producing effective progress notes is the various tools and resources that have been designed to assist in their creation. Perhaps the most well-known of these is progress note templates. Earlier on in this guide, we covered some of the key pieces of information that are generally included within progress notes. We understand that as a practitioner, particularly if you are new to the profession, it can be difficult to remember all of the exact requirements of what should be included. And that’s where templates can help. These formatting guides have been developed to work for practitioners in many different healthcare fields, and basically provide you with a way to structure your progress notes whilst still ensuring they include all of the important information.
SOAP
By far the most widely used of these templates is known as SOAP. SOAP notes separate the information into four different categories: Subjective, Objective, Assessment, and Plan. SOAP notes are extremely popular across a wide range of different healthcare professions; they allow practitioners to organize their patient records well without compromising the authenticity of their notes.
Subjective (S) - This section focuses on the client's feelings and experience of their symptoms. This may include when the symptoms started, whether they have improved or worsened, and how they impact the patient’s everyday life. Often, practitioners will include quotes as primary evidence for support.
Objective (O) - This section includes relevant factual data to support the symptoms reported by the client. Examples of evidence may include medical records, x-rays, examinations, test results, laboratory data, and vital signs.
Assessment (A) - This section is a combination of subjective and objective observations, including the current diagnosis, improvements noted, and specific tasks that may benefit the client.
Plan (P) - Includes the direct course of action for the client, focusing on any adjustments required for their treatment plan. This section should introduce specific goals for the client to achieve, as well as upcoming appointments and/or referrals.
BIRP
BIRP notes are typically used by mental health practitioners to document their sessions with clients. They are fairly similar to SOAP notes in the way that they are separated into four sections: Behavior, Intervention, Response, and Plan.
Behavior (B): This section includes both objective and subjective information regarding the patient. Frequently using quotes, the symptoms that are being experienced by the patient should be recorded, in addition to the practitioner’s objective observations of the patient. This may include comments on their behavior, appearance, and mood.
Intervention (I): The intervention section is focused on providing a concise summary of the session with the client, with emphasis on current goals and objectives. The practitioner should mention what strategies they used during the session and how these relate to the patient’s diagnosis and treatment.
Response (R): This part of the progress note relates to information regarding how the patient responded to the practitioner’s intervention and treatment strategies.
Plan (P): The note concludes with comments on the future plan of the patient, in particular the date and time of the next session and what the focus of that session will be on.
DAP
The DAP note bears significant similarities to the SOAP note, except it is written under three sections instead of four. Although the information included within a DAP note needs to be just as thorough as for a SOAP or BIRP note, it is often considered to be a simpler format.
Data (D): This section can be thought of as a combination of subjective and objective information and basically just covers all of the important information that was discussed during the session. This includes (but is not limited to) the patient’s symptoms, condition, behavior, affect, and responses to treatment.
Assessment (A): The practitioner basically takes the information provided in the data section, analyzes it, and reaches some sort of conclusion. This section may include a professional opinion of how the client is responding to treatment, whether or not they have made progress/achieved goals, and a probable diagnosis.
Plan (P): The final section combines all of the information provided to create a plan for the future treatment of the patient. This may involve specific details regarding the next session, the patient’s target goals, and any modifications to the current intervention.
As you can see, although these note templates are set out differently, they all cover much of the same information. There are specific details that are required to be recorded in progress notes, and following a template is the best way to ensure that this happens. The exact structure that you end up deciding on is entirely up to your preferences, and none of them are necessarily better than the others. However, whilst the specific template that you use makes little difference, we do think it is a good idea to take advantage of these formats. They are a useful way to ensure that your notes are consistent, accurate, and contain the right amount of detail.
Technology and progress notes
We are currently existing within a digital age, and as modern technology continuously advances, it is becoming more and more integrated into the healthcare industry. Although this may be somewhat frightening, technology has a lot to offer healthcare, and taking advantage of these new systems can lead to significant benefits for both patients and practitioners.
EHR (Electronic Health Records)
One of the most widespread applications of technology in the healthcare industry is through the use of EHR systems. EHR systems allow practitioners to electronically create all of their clinical documentation before uploading it into the system. Typically, EHR uses cloud-based technology, which means that data is stored in remote servers after it has been created, where it is accessible to authorized users. Cloud technology facilitates real-time updates, meaning that any changes or alterations to clinical documents happen in real-time, enabling more effective communication and improved quality of care. Using EHR systems eliminates certain challenges that practitioners face when writing progress notes, including legibility and accessibility. Furthermore, most EHR systems have high-end security measures in place that can help guarantee your patient data is securely protected at all times:
Controlled access: Every EHR system is integrated with controlled access, meaning that only authorized users are able to view and share data.
Authentication processes: Two-factor authentication is often included within EHR systems in order to increase the security of data. Data can be further protected by the use of palm, finger, or retina recognition or other biometric security measures.
HIPAA accountability: All EHR systems should be HIPAA-compliant, and it is the healthcare practice’s responsibility to ensure that this is the case. When researching different EHR systems to implement into your practice, you should evaluate the security measures that they have in place and their protocols in the case of a breach or data leakage.
Security programs: Security training programs are one of the most effective ways to ensure that employees are using systems correctly. When you implement any new type of software, it is essential that your employees are trained on how to use this so that the risk of accidental HIPAA breaches is minimized.
Electronic versus paper progress notes
When it comes to implementing electronic systems into healthcare practices, many practitioners remain doubtful. Although EHR systems have been widely implemented, there is still a lot of concern surrounding the benefits of electronic notes and some practitioners simply prefer to keep using the method they are most comfortable with. Although having preferences for the way you write your notes is completely understandable, there are certain advantages and disadvantages to manual and electronic note-taking that you should be aware of.
Electronic
- Pro: Electronic notes save practitioners a lot of time.
- Pro: They are much more likely to be free of spelling and grammar mistakes.
- Pro: Accessibility is significantly easier with electronic notes, as they can be stored on an online system where they are available 24/7 to authorized users.
- Pro: Electronic notes can be stored online where they are encrypted and protected by various security measures, making them more secure than handwritten notes.
- Con: Despite the security measures of electronic systems, any data stored online is at some risk of being jeopardized.
- Con: Some practitioners may find it difficult to get used to new electronic systems.
Handwritten
- Pro: Some practitioners will be significantly more comfortable with writing their notes handwritten than using a new system.
- Con: Handwriting notes is much more time-consuming than writing them electronically.
- Con: Handwritten notes are more prone to spelling and grammar mistakes.
- Con: More likely to be messy, unstructured, and in some cases, illegible.
- Con: Easier to be lost, damaged, or stolen, and when this occurs, it can be difficult to replace the original copy.
As you can see, although there are definite advantages and disadvantages to both of these methods, it is clear that electronic note-taking systems have greater benefits for practitioners. Additionally, the time and resources that will be saved by typing notes can be redirected into seeing more patients in need and improving the quality of care, indicating that these systems have benefits for clients as well as practitioners.
What should you look for in progress note software?
If you’ve made it this far through our guide and are interested in adopting some kind of progress note software, but don’t know where to look and what to look for, don’t worry - this is where we can help. The popularity of this type of technology has skyrocketed in recent years, leading to a massive increase in the number of vendors releasing software specifically designed to help practitioners. And whilst having more options is definitely a good thing, making a decision about which one to go with can be especially daunting.
We’re going to list some of the key features you want to look out for when looking into progress note software, but it is important to keep in mind that every healthcare business is different. The type of system that you use will be largely dependent on the size of your practice, the services you offer, and the software (if any) that you already have in place.
Configuration: Whilst most progress note software has been developed with the aim of assisting a broad range of professions, it is highly likely that some systems are more beneficial to certain fields of healthcare. For example, whilst progress note templates are incredibly useful tools, they only help if they are relevant to your specific profession. For this reason, we suggest ensuring that you look for customizable features that can be tailored to a variety of professions, including nursing, psychology, physiotherapy, and occupational therapy.
Integration: Given the advancements in healthcare technology and the increasing popularity of many systems, there is a high likelihood that your practice already has either an EHR or an EMR system in place. If this is the case, it is important that any new progress note software that you implement can be easily integrated into these pre-existing systems. Seamless integration means that all of the data you upload can be shared and transferred across systems, facilitating improved productivity and communication.
Billing: This is an area of healthcare that we haven’t gone into too much detail about in this guide, however, it is important to understand just how interrelated it is with clinical documentation. Because the notes that practitioners write are frequently used in the billing process to ensure the practice receives reimbursement, it is a good idea to look for high-functioning systems that integrate notes with billing.
Voice-to-text: Dictation tools included within software help streamline the note-taking process. Practitioners can significantly cut down on the time that they spend writing their notes, with the ability to complete their documentation at any time, from anywhere.
HIPAA-compliant: We won’t go into too much detail about the importance of compliance here seeing as we’ve already spoken about it, but ensuring that any progress note software you use is HIPAA-compliant is perhaps the most important factor to look out for. Without HIPAA compliance, your practice will be at risk of serious consequences, including fines, a damaged reputation, and losing patients. When you look into progress note software, you should clarify that they are HIPAA-compliant, and evaluate the security protocols that they have in place.
Examples of excellent progress notes
I think we’ve just about covered all the bases when it comes to how to write and store progress notes in the correct way. At the end of the day, no matter how much information you read about progress notes, practice is truly the only way you will become an expert. With that being said, we have compiled a list of example progress notes from a variety of different healthcare professions that should indicate to you the type of information and layout that is required for a good note.
Example of a Therapy Progress Note
Subjective
“I feel like I am a failure at work. I work as hard as possible, but I have always been overlooked, and my self-confidence plummets. It’s affecting how I am at home, and I’m beginning to feel miserable.”
Objective
Thomas had a flat expression and remained slumped in his chair throughout the session. He indicates feelings of low self-esteem that are beginning to impair his day-to-day life.
Assessment
This is Thomas’ first session, and he needs to find ways to communicate his emotions to his work while realizing his self-worth. Failure to do so will likely result in increased depressive feelings for Thomas.
Plan
Thomas will attend further sessions, and we have conducted a plan to work on his perception of self and ways to problem-solve at work. If symptoms do not improve within the next two weeks, a therapist or psychologist will discuss additional treatment and reevaluation.
Example of a Psychology Progress Note
Subjective
Luke states that he is constantly thinking, “I’m almost always thinking of ‘what-ifs,’ and once I start, it’s tough to get myself out of it. I’ll easily think for hours on end.” Luke claims it impacts his day-to-day life, “affecting my concentration as I can’t focus on university work or my job.” He also explains that “I don’t eat much anymore, as I just don’t get hungry.”
Objective
Luke displays significant signs of anxiety, and his symptoms have not improved from the past couple of therapy sessions. He demonstrates racing thoughts, a lack of concentration, and changes in appetite. His blood pressure levels are higher than average when tracked.
Assessment
Luke is not progressing in current treatment and so will benefit from an amended treatment plan. His symptoms have increased since the past two sessions, and he needs to have a more intensive focus on controlling techniques and monitoring meals.
Plan
I have worked with Luke today on a meal plan where he must check off eating meals at regular intervals, and we have also worked on more techniques involving breath control, mood regulation, and rumination avoidance. If Luke does not improve within the next two weeks, we will consider further or alternative treatment.
Example of an Acupuncture Progress Note
Subjective
Patient reports experiencing back pain. He first noticed the pain around 7 days ago, and it has begun impacting his ability to complete day-to-day tasks, in particular sitting at his desk for work. “I have had severe lower back pain for the past week. It hurts the most when I am sitting down”.
Objective
Completed regular testing. The patient had limited rotation in L4-L5 and reported pain upon movement. Left and right turns were within normal limits.
Assessment:
The exact moment of injury is unknown but likely a result of Qi-deficiency and blood stagnation. The patient reports symptoms worsening since the injury, so continuing treatment is recommended.
Plan:
The patient has been taught slow stretching exercises to be completed daily that should reduce some of the pain in his back, and was advised to avoid sitting down for long periods of time and to use seats with extra back support. The patient will return for a further session next week, where we will aim to stabilize his condition, control inflammation, and reduce spasms and pain.
As you can see, we chose to use a SOAP note format to provide our progress note templates, but feel free to utilize whichever structure works best for you. Although the specific information contained in a clinical note will obviously depend on your session with a client, these examples can help to indicate the type of information that you should include.
Final thoughts
We’ve finally covered everything that you should know when it comes to understanding progress notes; including why they are important, how to perfect them, and what tools and resources are available to assist you. At the end of the day, there are many different ways to write and store your progress notes, and every practitioner is going to have their own preferences. Although we are objective in this regard and understand that everyone works differently, we do think it is important to stress the usefulness of EHR systems and other progress notes software. This type of technology has been designed to elevate the productivity of a healthcare practice, saving you time and resources that can instead be redirected to seeing and treating patients in need. So despite your pre-existing methods, we are going to leave you with this final recommendation: go conduct some research into possible progress note systems and give them a go - you never know what you’re missing out on until you give it a try!
If you’re interested in furthering your knowledge of how progress notes fit into the wider healthcare system, we’ve found a selection of links that can help:
- Digital solutions for clinical documentation
- Sample Progress Note Templates in PDF
- Common Questions About Psychotherapy Notes and Their Answers
- Effective tips towards SOAP notes writing
- Writing case notes using the SOAP format
- Make sure your clinical documentation is on time and legible
- Record keeping guidelines
