What is a Clinical Progress Notes Template?
Clinical progress notes are an important tool to track the progress of your patients over time. They consist of multiple entries over different sessions or encounters with your patient, and are invaluable for informing clinical decision-making as well as for keeping well-organized and comprehensive clinical documentation.
Our clinical progress notes template makes it easy to organize your clinical progress notes. This template is a blank slate with enough structure to ensure you can keep your notes organized, but enough customizability to ensure whatever method of note-taking you prefer can be accommodated.
This resource is a downloadable, interactive PDF that you can either fill out digitally, or print out and fill in by hand. The provided template is a framework for you to standardize your clinical progress notes, allowing you to reduce the time spent formatting notes and increase the time spent tending to your patients.
How to Use this Clinical Progress Notes Template PDF
It couldn’t be simpler to use our simple clinical progress notes template. Just follow these easy steps to start taking your clinical progress notes.
Fill in the patient details
This is a very important section and it is crucial to check for spelling errors or alternatives in the patient’s name, or optional identifier.
Add the date and time
Including the date and time in the clinical progress in your note is important for creating a clear picture of your patient’s progress. We have included a date and time column for this reason.
Write your clinical progress note entry
Add in the update you wish to make in the Notes column, try to keep it concise, legible and at a level that can be understood by those who will be sharing these clinical progress notes.
Sign the clinical progress note
For legal purposes, and for traceability, add your signature at the bottom of the document if you have not already done so.
Store your progress notes securely
As clinical progress notes serve as part of your patient’s medical record, you have a legal obligation to store your clinical progress notes safely and securely under HIPAA.
Clinical Progress Notes Example (Sample)
Clinical progress notes will look very different from patient to patient, but to show you what this template might look like once it’s finished, we have created an example clinical progress note.
Who Can Use this Clinical Progress Notes Template?
Clinical progress notes can be used by any clinicians who see patients independently on a long-term basis. This might be:
- Clinical psychologists or counselors
- Massage therapists, occupational therapists or physiotherapists
- Nurses and nurse practitioners
- Specialist physicians
- General practitioners
And many more!
We have kept this template broad enough so it can be used by a whole range of clinicians. Anyone who needs to routinely take progress notes for their patients can benefit from using our clinical progress notes template. Additionally, students or trainees in a clinical discipline may find this template a useful tool for developing their progress note-taking skills.
Why is This Template Useful for Clinicians?
This template saves you time designing, formatting, and drawing up your own clinical progress notes table. The clinical progress notes template also helps clinicians track the important updates on their patients using the Date/Time column.
Make sharing simple
Clinicians often have to share their notes with other specialists, healthcare workers, or other third parties, and ensuring their clinical progress notes are clearly set out and readable will help to improve the coordination of care for their patients.
Keep your clinical progress notes organized
Having separate documents for every progress note, regardless of how concise they may be, can lead to losing certain days or losing track of the order of your notes. By using a template with a section for the date and time, as well as five entries per page, you won’t need to worry about organizing an endless stack of pages again!
Benefits of Using the Clinical Progress Notes Template
Using a standardized template for your clinical progress notes can have various benefits for your medical practice. Some of these benefits are:
Keep your notes readable
Progress notes may be shared with the patient, other clinicians, or insurance companies and so it is crucial that they can be understood. Using a simple template like our clinical progress notes template keeps your notes organized and legible, making it much easier for others who need to read your notes in the future.
Make audits a breeze
Clinicians are often subject to audits of their practice to ensure they are abiding by the laws and regulations that apply where they operate. Using a simply laid out template shows an auditor you have a standardized practice for your clinical progress note-taking.
Aid your reflective practice
Looking back over your patient’s progress, checking what worked, what didn’t, and how you could improve is a great practice to get into. Our clinical progress notes template makes it easy for you to reflect on your practice, and constantly improve as a clinician.
Unified, professional look
Having all your clinical notes standardized with the same simple and professional template helps you to build your practice’s design style and convey a unified and polished look to your clients or colleagues.
Suits digital or print-out
This template can benefit practices that are paper-based or those that utilize an electronic health record system, such as Carepatron. Simply print out the PDF of this clinical progress notes template and write directly into it, or fill in the interactive PDF text boxes digitally.
Why Use Carepatron For Clinical Progress Notes?
Software like Carepatron offers an easy-to-use, HIPAA-compliant method for you to electronically store your clinical progress notes. Carepatron is a fantastically integrated practice management software designed to save you time, keep your practice organized, and improve your coordination of care for your patients. Carepatron also offers you a vast library of templates for use in your practice, and much more!
Picture this, you access your calendar from within Carepatron and see your appointments for the day laid out clearly with customizable tags. Head to your client’s profile within Carepatron to access all their documentation, including the clinical progress note template you began the previous session. Once their session is over, you open up the template again and use Carepatron’s smart voice-to-text software to dictate the update to their progress notes for today and securely save the note. Manage your client’s billing and follow-up appointment from the billing and appointments tabs in Carepatron, and get on with seeing patients!