A progress note is an essential document created by healthcare professionals to update a patient'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.
Progress notes are legal documents and are required each time there is an interaction between client and practitioner. Any competent and compliant clinician will keep a detailed set of progress notes for each client they see.
Top reasons to record progress notes
There are plenty of reasons to keep progress notes; these are just some of them;
Progress notes are a contract between the client and clinician. They are where treatment goals and treatment plans can be discussed and decided on before they are put into a document to track the treatment progression.
Progress notes provide a means of communication within and between care teams. They enable healthcare workers who provide care for the same client to know what occurred in the last session or their last acute episode—allowing them to provide the most appropriate and accurate treatment for their presenting issue.
No matter how good your memory is, as a healthcare professional, remembering details about every session can take a tremendous toll on your mental load. Writing them down provides an important reference point for you and ensures you can build rapport with each client by remembering essential details about each session.
Finally, progress notes are legal documents, and whether you like it or not, by law, you are required to keep a record of each client's care history for regulatory, insurance, and legal purposes.
Without the right formula writing progress, notes can be a lengthy process. Using a format such as SOAP notes 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.
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
- Prioritize your notes. Letting them build up will only make the problem worse
- Use a template such as SOAP to help you
- Capture and store your progress notes on a secure practice management platform.
- Voice transcription. Yes, it's a thing (click here to find out how you can use it)