Progress Notes Template
A concise and practical progress note template is guaranteed to improve the quality of your documentation while saving you countless hours.
Fact Checked by RJ Gumban.
What Is A Progress Notes Template?
A progress note is part of a medical record where healthcare practitioners detail information regarding a patient’s progress during treatment. Progress notes are used across a wide range of different healthcare specializations and they are critical in improving communication and helping to ensure all clinical decisions are well-informed. There are many other formatting structures that healthcare practitioners use to organize their progress notes, but all of these contain similar types of information. Some of the most common progress note templates are SOAP, BIRP, and DAP.
At the end of the day, regardless of the specific type of template that you use, progress notes all have the same function - to improve the quality of care. As such, each of these templates covers pretty much the same information, just in a different way. To make things as easy for you as possible (and with the additional advantage of saving you a lot of time), we’ve created an intuitive template that essentially synthesizes all of the information that’s included in a progress note. You can download the template and edit it however you need, helping to guarantee effective communication within your practice, leading to better health outcomes and an improved care delivery process.
Printable Progress Notes Template
Check out these progress note templates to improve clinical documentation, productivity, and treatment outcomes.
How To Use This Template For Progress Notes
We understand that healthcare practitioners lead very busy lives, so we’ve tried to make sure that using our progress note template is as simple a process as possible. To get the most out of this resource and create accurate progress notes, simply follow these four steps:
Download the PDF
First thing’s first: you need to download the PDF onto your device. We’ve included a link to the progress note template on this page, and all you need to do is click on and it will take you to the PDF template.
Make the appropriate changes
Once you have downloaded the PDF, you’ll be able to edit it as necessary. Progress notes are best written immediately after a session with a patient, so once you have wrapped up an appointment you should access your template and begin making the necessary changes.
Double-check credentials
Before you save your progress note, it is a good idea to double-check the credentials that you’ve recorded. Progress notes are legal documents that can be used in a range of different situations, so it’s very important that the credentials you include are accurate.
Store the progress note securely
After you have written your progress note, you need to store it securely. Because progress notes contain confidential PHI, HIPAA guidelines require them to be protected against any unauthorized access. There are different options for securely storing progress notes although we would recommend using an online platform, like Carepatron, which employs high-quality protection software.
Progress Notes Example (Sample)
Sometimes the best way to learn how to use a new resource is to see it in action. This is why we’ve created a sample progress note template, with each section appropriately filled out. Although the specific information that you include in your progress notes will differ depending on the content of your sessions with patients, the general structure will always remain the same. This sample should highlight the specific kinds of information that are applicable to each section of the progress note.
Check out and download the Progress note example here:
Who Can Use this Printable Progress Notes Template?
Finding resources that can be applied to your specific kind of work can sometimes be difficult. Healthcare is diverse, and templates are often highly specific to certain fields. While this in itself isn’t a bad thing, it does make it more difficult for some practitioners to find suitable resources - which is where we come in. Our progress note is highly applicable to a range of different healthcare practitioners working in various fields, including:
- Psychologists
- Psychiatrists
- Counselors
- Physical Therapists
- Occupational Therapists
- Massage Therapists
- Mental Health Therapists
- General Practitioners
- Nurses
- Speech Language Therapists
- Chiropractors
Additionally, this progress note template can be used for treating patients of all different ages, including children, teenagers, and adults. Using a progress note template that is highly applicable for various patients and practitioners will help improve consistency while also ensur
Why Is This Template Useful For Healthcare Practitioners?
Our progress note template has a range of different everyday uses for healthcare practitioners:
- Organization: Healthcare providers typically lead very busy lives, making it difficult to be completely organized all of the time. Nevertheless, finding tools that assist with organization is very important, and that is exactly what our progress note template aims to do. The document can be easily accessed, edited, and stored, helping you stay productive and organized.
- Accuracy: It can be hard to remember all of the different parts of a progress note. By using a template, this responsibility is no longer yours - the resource is separated into different sections to ensure that you include all of the necessary information.
- Timeliness: Staying on top of clinical documentation can be hard. Writing progress notes is a time-consuming process, especially if you treat a large number of clients. Finding ways that can reduce the amount of time spent on writing documentation is therefore in your best interest. With our progress note template, you won’t have to worry about any formatting or structuring, as it’s already been done for you!
Why Use Carepatron For Progress Notes?
Writing progress notes that are consistently effective and accurate can be quite a time-consuming process for healthcare practitioners. Identifying solutions that help to streamline this process without compromising the quality of the finished documents is thus always a good idea, which is where Carepatron comes in. Carepatron is an all-in-one healthcare software that has developed a sophisticated and easy-to-use solution for creating and storing clinical documentation. With Carepatron, you will have access to a wide range of different progress note templates, as well as voice-to-text transcription software. This software allows you to simply speak into your device and the platform will translate what you say into text, a process that is guaranteed to save you countless hours!
After you have created your progress notes, you can store these documents using Carepatron’s platform. Carepatron is a cloud-based solution that takes security seriously. It is entirely HIPAA-compliant and employs stringent physical and electronic safeguards to ensure the privacy of your patients is protected at all times.
Finally, in case you are looking for more diverse solutions, we would be remiss not to briefly mention Carepatron’s other capabilities. In addition to streamlining clinical documentation, Carepatron is integrated with medical billing, coding, appointment scheduling, automated reminders, a patient portal, online payments, and extensive telehealth tools… pretty much everything you need to optimize your healthcare business!
Commonly asked questions
The length of a progress note will largely depend on the type of session you have had. With that being said, keeping a progress note to 1-2 pages is a fairly good benchmark. If you conducted tests and examinations in your session or changed a treatment plan, then you could expect the corresponding progress note to be longer than if it was a standard check-up.
Progress notes are legal documents and can be viewed by both other healthcare providers and the patient, so you need to maintain professionalism at all times. Avoid using any judgemental or possible offensive language, and don’t use medical jargon or abbreviations that aren’t universally understood. After you write your progress notes, it’s a good idea to give them a quick overview to ensure they contain the correct information and maintain professionalism.
Because progress notes are legal documents, they are required in pretty much every healthcare field. They are used primarily to track the progress of a patient and play a massive role in clinical decision-making. As such, nurses and healthcare providers should be writing progress notes after each session or encounter that they have with a patient.
