Progress Notes For Mental Health Counselors Template

A progress note for a mental health patient is a detailed record of the patient's status, treatment, and progress during a therapy session or clinical encounter. It documents the patient's current mental state, any significant events or behaviors since the last session, the therapist's observations and clinical impressions, the interventions used, and the patient's response.

Mental health notes should be clear, concise, and objective, focusing on observable facts rather than subjective interpretations. Notes should avoid jargon, use person-first language, and maintain patient confidentiality. Timely documentation, typically within 24 hours of the session, is important for accurate record-keeping.

The most common format for documenting relevant information in progress notes is the SOAP note format, which stands for Subjective, Objective, Assessment, and Plan.