Counseling progress notes can be created using different platforms, plans, and formats. The shape that your progress notes take may differ from other clinicians, but as long as they cover vital criteria, these differences do not matter. A counseling progress note template has been created using ICANotes. This example includes subheadings of behavior, the content of therapy, therapeutic intervention, and diagnosis.
Progress notes should be brief, quickly understood, and objective information to assist the client, practitioner, and other relevant healthcare workers and insurers. The following is counseling progress notes template using a SOAP structure.
Subjective Section: Patient’s subjective reflections and opinions regarding their experience of the treatment plan. Includes direct quotes from the client.
Objective Section: Information collected by the practitioner, including results from screening tests and other data that has been obtained.
Assessment: Practitioner’s clinical assessment of the client utilizing available subjective and objective information.
Plan: Details of the treatment plan devised for the client and developed goals and any further follow-up treatments or assessments.
Drive your success with progress notes
Using progress notes in your business is an effective method of combining relevant information and ensuring professionality for the benefit of clients and clinical counselors. Writing progress notes in therapy allows for necessary data to be shared across healthcare providers and ensures that the client's process has been effectively recorded. This article provides:
- Information on the various benefits of progress notes
- Outlining different techniques
- Formats that can be utilized by clinical counselors in their creation of practical progress notes