What is a progress note?

A progress note is an important part of a client’s mental health record, serving as a summary of the client’s status and progress in each psychotherapy session. Most therapists and mental health professionals use a Progress Note Template to help with documentation.

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In most cases, the progress note will be the most ubiquitous document in the client’s medical record as it captures the snapshot of the therapeutic work from each meeting.

Because of it’s importance and the frequency in which the therapist uses it, most therapists chose to use a progress note template to streamline the process of composing the note.

But what exactly should be included in a progress note, and in what order? It’s a more involved question than one might think. There is no gold-standard progress note template, and many such templates have been adopted over the decades. Nevertheless, many such templates feature the same core components (although the terminology for these components and their organizational order may differ). We will review these components below.

How do you write a progress note?

Let’s review each of the common sections of a progress note, with included examples for each component to help you visualize how the note would look in written form.

The generally agreed-upon sections of a progress note are: session information (who, what, when, where), diagnosis, topics/issues talked about in session, clinician’s therapeutic intervention(s), clinical notes, clinical assessment(s), and future plans.

Session information

A progress note most often begins with general information about the session, including the client’s name and date of birth; session date, time, and duration; service code; session type; and participants in the session.

Example
Client’s Name: Jane Smith
Date of Birth: 07/01/1980
Session Date: 08/10/2022; Time: 4:00PM; Duration: 45 mins
Service Code: 90834
Session Type: Online
Participants: Client, client’s partner

Diagnosis

The diagnosis section consists of the applicable diagnosis code for the client from the ICD-10 and a written description of the diagnosis.

Example
Diagnosis Code: F33.1
Diagnosis Description: Major Depressive Disorder, Recurrent, Moderate

Topics/Issues discussed

The topics section usually includes a list of the therapeutic topics discussed during the session. This section is usually brief and can sometimes be found as a list on templates.

Example
Topics Discussed: Client’s recent experience with major depression, which has been exacerbated by the loss of a valued relationship.

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Interventions

The interventions section includes the therapeutic interventions used by the clinician in the session. This section is also usually brief and oftentimes will be found as a list on many templates.

Example
Intervention(s): Expression of feelings, Processing

Notes

The notes section includes additional clinical information that the therapist may want to add to the progress note. This can include the rationale for therapeutic interventions listed above; client symptomology, including any changes in intensity, duration, and/or frequency of relevant symptoms; a report of the client’s progress toward treatment goals; any clinically significant divergences from the client’s baseline mental status or functioning; and any other objective relevant content.

Example
Notes: Therapist supported client with expressing her feelings about an old friend’s decision to end their relationship, as well as emotional processing regarding this issue, as the client reports that this event has increased intensity and frequency of feelings of self-loathing and isolation.

Assessment

The assessment section includes the clinician’s assessment of the client’s mood, affect, mental and functional status, and a risk assessment if needed.

Example
Assessment: Client’s mood was depressed and affect flat throughout the session. Mental status was slightly impaired to recent history and otherwise intact. Client reported no risk of harm to self or others and presented no counter-indicators to her self-report.

Plan

The plan section includes any mutually agreed upon goals or objectives for the client between the current session and the next; any expected coordination of care between the therapist and other providers, or plans of areas of therapeutic exploration in future session(s).

Example
Plan: Therapist and client will meet again on 02/01/2022 at 4PM. Therapist has provided the client with a processing exercise to use as needed to manage grief and depressed mood over the next week.

Signature

Lastly, the provider’s name and practice information should be included in the progress note and the provider should sign the progress note when it is completed.

Conclusion

While the section titles and the order of the sections themselves may vary from one template to the next, the content of the above sections should be included in most therapeutic progress notes under most circumstances. It is important to note, however, that every organization and insurance provider has its own unique policies, and therefore it’s always recommended for therapists to review the documentary requirements of all affiliated agencies to ensure you are meeting your contracted documentation standards.

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Credits

Image by Jan Vašek from Pixabay