Mental Health Progress Notes

Progress notes are detailed notes written by a clinician containing essential information regarding a session with their client. Mental health practitioners create mental health progress notes with objective and subjective information about the patient, the treatment plan designed for the patient, and any observed progress.

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A brief introduction on progress notes

A brief introduction on progress notes

Progress notes are detailed notes written by a clinician containing essential information regarding a session with their client. Mental health practitioners create mental health progress notes with objective and subjective information about the patient, the treatment plan designed for the patient, and any observed progress. Once written, these progress notes must be stored securely and confidentially, aligning with a medical compliance program

The progress notes need to be succinct, accurate, and relatively objective, as they are often shared between other people working with the patient, including healthcare practitioners and insurers. Progress notes can also be used in legal situations to evaluate the decisions made by practitioners. To consolidate your knowledge, we have compiled information regarding why mental health progress notes are so important, different formatting structures that can be used, and general pitfalls that should be avoided.

What is a progress note in mental health?

A mental health progress note refers to a progress note created by a mental health worker, documenting the relevant information from a session with their client. These progress notes highlight the patient's treatment plan, their progress in treatment, and general observations about behavior. 

How do I document a mental health assessment?

Different methods of documenting mental health assessments can be utilized, depending on what suits the practitioner and whether they conduct their work remotely or in person. Mental health care practitioners often use online services that provide electronic records for your practice. These services are an effective way to ensure the safety and privacy of mental health assessments while also being accessible and organized for the practitioner.

How do you write a mental health progress note?

Writing a concise mental health progress note can seem like an overwhelming task. This process has been simplified by various formatting structures developed to ensure that progress notes are written adequately and convey the appropriate information. Practitioners in different fields, including psychologists, psychiatrists, and counselors, will vary in the information included in progress notes relative to the service being provided. Practitioners will differ in whether their progress notes are hard copies or written electronically and whether they take their notes in-session or afterward. 

Despite these differences, health care workers may structure their progress notes using formats that provide guidelines for how progress notes should be written, including SOAP, BIRP, and DAP. Generally, mental health progress notes include subjective and objective information regarding the patient and how they are responding to treatment and comments on the treatment plan and any progress observed in the patient.

How do you write a mental health progress note?
Mental health progress notes example + template

Mental health progress notes example + template

Of the formatting guidelines mentioned previously, SOAP is likely the most commonly used technique. It categorizes the information necessary for progress notes into four sections. We have included a summary detailing what these sections entail:

  • Subjective (S): Covers information regarding the patient and the issues they are experiencing. This section often includes direct quotes from the patient.
  • Objective (O): Includes factual information, like assessment results, symptoms, and the behavior, attitudes, and cognitive functioning of the patient.
  • Assessment (A): A resulting interpretation of the subjective and objective information. It includes observations of the patient’s progress and perhaps the risk of safety or harm.
  • Plan (P): Outlines the treatment plan designed for the patient and establishes the next set of objective goals. 

BIRP formatting structures are also commonly used to create mental health progress notes. Although they contain similar information to SOAP notes, their design differs slightly:

  • Behavior (B): Combines subjective and objective information about the patient’s behavior. Often includes quotes from the patient.
  • Intervention (I): Explains the methods to target specific symptoms or issues, e.g., prescribing sleeping aids to improve insomnia. 
  • Response (R): Describes how the patient responds to treatment, including their opinions and reactions. 
  • Plan (P): Contains information regarding the future steps for the patient, including goals and objectives for the next session. 

ICANotes have created a mental health note template based on a session with a psychotherapist. The template organizes information into behavior, therapy content, therapeutic intervention, and diagnoses/plan.

Pitfalls to avoid while writing mental health progress notes

Guidelines to writing a practical mental health progress note can be further consolidated by knowing the information that shouldn’t be included and common pitfalls that can lead to ineffective progress notes:

  • The dangers of hard-copy notes: Although some mental health practitioners may prefer hard-copy notes, it is important to use neat, legible writing and ensure they are kept in a safe, secure location at all times. A better alternative would be to use an electronic system that organizes and encrypts your progress notes. 
  • Vague language: The language in a mental health progress note is critical; these notes can be shared with other health care workers related to the patient. They can also be used in court or in situations where the practitioner must support their decisions in treating a patient. To ensure these documents do not disadvantage the practitioner or the patient, clear, specific language should be used without any vague or misinterpretable comments. 
  • Please don’t skip any necessary information: Although writing progress notes can be time-consuming and repetitive, it is crucial to include all relevant information in the proper detail. As mentioned, the possibility of these documents being used in legal situations means they should always contain the names of the patient and practitioner and accurate dates, times, and signatures. 

Final thoughts

Hopefully, this article has consolidated your knowledge on the different ways that mental health progress notes can be written, why they are important, and common pitfalls that should be avoided. 

Recently, services have been developed that improve the organization and safe storage of progress notes. Carepatron is a platform that safely secures clinical progress notes and provides various templates that practitioners in different fields can use. Documenting mental health progress notes electronically allows practitioners to organize all of their information while guaranteeing safe-keeping effectively. 

Although there are numerous formats to help write progress notes, including SOAP and BIRP, you will have seen that these contain similar information. When writing mental health progress notes, the essential aspect is ensuring that the required information is documented in a digestible format. 

Further Reading:

Pitfalls to avoid while writing mental health progress notes

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