Learn how to write therapy progress notes to document session details. Download our free therapy progress notes templates.
What are Mental Health Progress notes ?
Therapy progress notes are a record clinicians use to document each therapy session. They detail the client’s condition, what happened during the session, and the client’s response to treatment. Clinicians are legally and ethically required to create these notes for each client’s medical record.
How to write therapy progress notes?
There’s no single way to write progress notes. Many therapists use electronic health systems (EHR) with templates to streamline the process. EHR notes are also consistently legible, a key requirement.
While some therapists prefer paper notes for in-session completion, illegibility and divided attention are risks. A hybrid approach with paper notes for later EHR entry or paper templates scanned into EHR notes can be helpful, especially for new clinicians ensuring they cover all important areas.
Essential Elements for Therapy Progress Notes
The specific content required in progress notes can vary based on your location, licensing board, and other factors. However, all progress notes should generally include the following core elements:
Client demographics: Name, date of birth, session date and time, clinician name and signature
Client presentation: Description of the client’s mood, affect, behavior, and any relevant symptoms reported by the client or observed by the clinician. This section should paint a picture of the client’s emotional state and any changes since the last session.
Diagnosis: A formal diagnosis code based on the client’s symptoms and clinical judgment.
Safety assessment: An evaluation of potential suicidal ideation or self-harm risk. This may be documented as a routine check-in for high-risk clients or prompted by specific disclosures during the session.
Medication updates: Any changes, additions, or client adherence to medications prescribed by a psychiatrist or other healthcare provider. This can include the medication name, dosage, and how the client is tolerating it.
Treatment plan: A detailed account of the interventions used during the session, recommendations provided to the client, the client’s response to these interventions, progress made towards established goals (both short-term and long-term), and any necessary adjustments to the treatment plan based on the client’s progress and feedback.
Post-session plan: Tasks assigned to the client to work on before the next session, topics to be addressed in the next session, and scheduling of the next appointment. This helps the client stay engaged in the therapeutic process and provides a clear structure for future sessions.
Client Progress Note Template
This section provides a detailed example of how a therapy progress note might be written, including the following elements:
Client Information: Clinician name, agency name, address, client name, date of birth, diagnosis.
Session Details: Date, start and end time.
Client Concerns: What the client reports feeling and experiencing.
Clinician Observations: The clinician’s observations about the client’s appearance, behavior, and emotional state.
Session Content: What was discussed and explored during the session.
Interventions: The techniques and approaches used by the clinician during the session.
Assessment: The clinician’s evaluation of the client’s condition based on the information gathered.
Plan: The agreed-upon steps for the client to take moving forward and the next appointment details.
▶ HIPAA & Insurance Hassle-Free:
Combines compliance for a smoother workflow.
▶ Supports All Note Formats (SOAP, DAP, EMDR & More):
Emphasizes broad note type compatibility.
▶ Seamless Documentation for Every Therapy Setting:
Highlights catering to various therapy needs.
▶ Your Way, Your Notes: Record, Dictate, Type, or Upload:
Focuses on user preference and flexibility in note creation.
Client Progress Note Example
Clinician Name
Agency Name
1234 Office Address
Wherever, UR 12345
Client Name: Jane Doe
Client DOB: 02/03/4567
Diagnosis: F 33.1, Major Depressive Disorder, Recurrent, Moderate
Date: 04/05/6789
Start Time: 10:15 am
End Time: 11:00 am
Client’s Subjective Concerns/Chief Complaint: “I’ve been feeling more down lately.” Client expressed concerns about her mood, reporting feelings of sadness, fatigue, difficulty sleeping, lack of energy, and a tendency to withdraw from her friends.
Clinical Observations: Client appeared unkempt, which is a noticeable change from previous sessions. She sat with a slouched posture at the start of the session, and appeared weary, with slow movements and a subdued mood. She was attentive and cooperative, with an appropriate and consistent affect. Client denies any thoughts of suicide.
Issues and Stressors Discussed/Session Description: Client discussed worsening depressive symptoms beginning last week after a disagreement with a friend. She detailed the argument, which happened late on Wednesday night, leading to only 3 hours of sleep. Despite this, she continues to attend work and reports adherence to her medication regimen.
Client mentioned that the argument has since been resolved, and communication with her friend has resumed, although she still experiences thoughts like, “What’s the use? They don’t get me.” Further discussion revealed that since Wednesday night, the client has been spending more time than usual on her phone at night, getting insufficient sleep (4-5 hours), negatively affecting her energy and mood. When this writer mentioned her phone use, she rolled her eyes but then laughed, saying, “I know, I know, I’m doing it to myself.”
Interventions/Methods Provided: Discussion of symptoms, supportive counseling, exploration of emotions, Psychoeducation: Cognitive Behavioral Therapy techniques, discussion of contributing factors, sleep hygiene handout provided. Review of client’s safety plan.
Assessment: While the client’s symptoms and presentation align with depression, the sudden change appears to be triggered by the argument and poor sleep. The client’s emotional response to the disagreement and subsequent lack of sleep are likely causes of the sudden mood and appearance changes. Client does not currently seem to be at risk for suicide, mentioning the importance of being there for her younger sister and pet cat, and agrees to follow her safety plan if symptoms worsen. However, the client may experience further depressive episodes if she cannot manage her sleep and stress effectively.
Plan: Client has agreed to establish a regular sleep schedule, starting tonight, and to put away her phone an hour before her 10 PM bedtime. She will monitor her symptoms and contact this writer if they worsen. If there is no improvement by the next session, this writer may suggest that the client contact her psychiatrist for an earlier appointment, as the next follow-up is a month away.
Next Appointment: 04/12/6789
Clinician Signature: ____________________________________
Clinician Printed Name, LCSW
What are the different types of mental health progress notes?
There are several widely used formats for progress notes that can streamline your note-keeping while covering all essential points:
DAP (Description, Assessment, Plan)
BIRP (Behavior, Intervention, Response, Plan)
SOAP (Subjective, Objective, Assessment, Plan)
Although these templates are similar, each has distinct features that may make one more suitable for you than another. For instance, SOAP notes, designed for healthcare settings, might be less subjective than DAP notes, which can provide more flexibility for discussing nuanced aspects of mental health. On the other hand, clinicians who struggle with open-ended descriptions might prefer the structured approach of SOAP or BIRP notes.
SOAP and DAP notes both include an assessment section, unlike BIRP notes, which focus more on the client’s response to interventions rather than their overall condition. This assessment can be crucial, especially for health insurance purposes or in settings where you need to regularly justify continued treatment. As a result, many clinicians favor SOAP or DAP formats.
Ultimately, consider your strengths and challenges as a note-taker. If you tend to write lengthy, detailed notes with too much personal or subjective information, a more structured format like SOAP or DAP might help you be more concise. However, if these formats feel too restrictive, you might prefer to create a custom template that meets all necessary criteria without fitting into predefined categories.
Are progress notes the same as psychotherapy notes?
It’s important to understand that progress notes and psychotherapy notes are not the same. Psychotherapy notes are private, kept separate from the client’s medical record, and intended solely for the clinician. They can be subpoenaed, but only if specifically ordered by the court.
Psychotherapy notes are useful for remembering personal details shared by the client, treatment directions, or internal reflections for discussion with a clinical supervisor—information that would be inappropriate for the client’s progress notes.
For clinicians who need to document extensive details but tend to over-share in the description section of DAP progress notes, psychotherapy notes can serve as a useful supplement.
How to use therapy progress notes with your EHR?
You can integrate digital notes with your EHR in various ways. You can upload a template or follow the structure provided by your software. A top-rated EHR will include a dedicated section for notes and documentation, along with easy-to-use templates built into the platform.
Enhancing Practice Efficiency with EHR Integration
Incorporating digital notes into your EHR system not only streamlines your workflow but also enhances the overall efficiency of your practice. With a comprehensive EHR, you can easily manage therapy progress notes, which are crucial for tracking client progress and maintaining accurate records.
- Dedicated Note Sections: Look for EHR systems that offer a dedicated area for notes and documentation, ensuring that all critical information is organized and easily accessible.
- User-Friendly Templates: These templates simplify the documentation process, saving valuable time and reducing the potential for errors.
- Comprehensive Practice Management: A robust EHR system goes beyond just note-taking. It can support appointment scheduling, billing, and even client communications, providing an all-in-one solution that can transform how you manage your practice.
Integrating your progress notes into an EHR not only keeps your records secure and compliant but also frees up more time to focus on what truly matters—providing exceptional care to your clients.
Cracking the Code:
Now, let’s decode the secrets of clear and compliant note-writing:
Structure matters: Organize notes logically, using headings and bullet points for clarity.
Chronological order: Describe events in the order they occurred.
Specificity is key: Use specific descriptions of client behavior and interventions.
Document progress objectively: Focus on observable changes and avoid subjective interpretations.
Link interventions to goals: Clearly explain how interventions connect to treatment goals.
Meeting the Mark:
Remember, your notes need to align with insurance requirements to ensure smooth billing:
Verify coverage: Understand the specific requirements of your client’s insurance plan.
Use approved codes: Utilize correct diagnosis and procedure codes for billing.
Justify medical necessity: Clearly document the rationale for treatment and its link to diagnosis.
Maximizing Reimbursement:
Here are some essential tips for maximizing your reimbursement potential:
Submit notes promptly: Don’t delay submitting notes to avoid claim denials.
Proofread meticulously: Ensure accuracy and completeness to minimize errors.
Use clear and concise language: Avoid jargon and ambiguity to facilitate understanding.
Collaborate with billing specialists: Seek guidance and support with insurance billing complexities.
Beyond the Basics:
Looking to boost your note-taking efficiency? Consider these advanced strategies:
Utilize templates: Develop standardized templates for specific types of sessions.
Embrace technology: Explore dictation software or AI-powered tools like S10.AI Robot AI Medical Scribe for faster note-taking.
Dictate notes during sessions: Capture key points in real-time for improved accuracy.
Invest in note-taking training: Enhance your skills with specialized courses or workshops.
Embracing Technology: Your Gateway to Streamlined Therapy Notes and Efficient Billing
While mastering the fundamentals of therapy notes is crucial, embracing technology can truly elevate your practice. Imagine dictating notes in real-time, freeing your mind to fully engage with your client. Or picture leveraging AI-powered tools to automatically generate summaries and identify key themes in sessions, saving you precious time and effort.
This is where S10.AI, your AI-powered Robot AI Medical Scribe, steps in. S10.AI acts as your intelligent assistant, capturing every detail of your sessions through secure voice recognition and transcribing them into clear, accurate notes. But S10.AI goes beyond simple transcription. Its advanced algorithms analyze session data, providing you with valuable insights into client progress, treatment effectiveness, and potential areas for further exploration.
Benefits of S10.AI for Therapy Notes:
Data-driven insights: Gain deeper understanding of client progress and tailor interventions accordingly.
Reduced stress and burnout: Spend less time on paperwork and more time on what matters most – your clients.
HIPAA compliance: S10.AI ensures secure data storage and access, protecting client privacy.
Remember, technology is meant to empower you to practice more effectively and efficiently. By integrating S10.AI into your workflow, you can streamline therapy notes, optimize billing processes, and ultimately deliver exceptional care to your clients.
Empowering Therapists and Enhancing Patient Care
In conclusion, S10.AI Robot AI Medical Scribe presents a revolutionary solution for streamlining therapy note creation and insurance billing. By automating tedious tasks, the S10.AI empowers therapists to focus on what truly matters: building rapport, delivering personalized care, and achieving optimal patient outcomes. This technology not only improves practice efficiency but also enhances the quality of care by ensuring accurate, comprehensive documentation. With its commitment to data security and patient privacy, S10.AI offers a reliable and ethical partner for therapists navigating the complexities of insurance billing. As the future of healthcare unfolds, AI-powered tools like S10.AI hold immense potential to revolutionize the therapy landscape, fostering a more efficient, patient-centered, and sustainable model of mental health care.
