How to Write Progress Notes: Examples & Best Practices

What are Progress Notes?

Progress notes play a crucial role in mental healthcare by documenting client information, medical history, and progress throughout their consultation sessions. These notes are essential for effective collaboration among all parties involved in the client's treatment. They help ensure seamless communication and continuity of care between therapists and clients.

Types of Progress Notes

Different types of progress notes are used based on the specific strategy being applied for each client. Below is a brief overview of some commonly used progress notes:

1. BIRP Notes

BIRP notes are structured to document the following:

• Behavior: Behaviors observed by the therapist that include emotional, physical, or even verbal expressions during the session.
  
  Example: ‘The client looked nervous and did not make eye contact.’
  
• Intervention: Actions taken by the healthcare provider, such as therapy methods or medical procedures.
  
  Example: ‘Conducted cognitive behavioral therapy focused on reducing anxiety triggers.’
  
• Response: The client's reaction to the intervention, including any measurable changes or feedback provided.
  
  Example:‘There was an improvement in the client’s anxiety level; he said he felt slightly less anxious than before after the session.’
  
• Plan: Every change that will be made and incorporated in the future, such as arranging follow-up meetings or implementing new measures.
  
  Example: ‘The next session will involve the client in mindfulness training.’

2. SOAP Notes

SOAP notes are among the most common documentation structures used in healthcare and therapy. They include the following four components:

• Subjective: The client’s account or re-telling of their experiences or feelings.
  
  Example: ‘I feel overwhelmed all the time and have trouble sleeping.’
  
• Objective: Observations or measurable data gathered during the session.
  
  Example: ‘The client displayed visible signs of anxiety, including fidgeting and difficulty maintaining eye contact.’
  
• Assessment: The therapist's clinical interpretation based on subjective and objective data.
  
  Example: ‘The client is experiencing symptoms consistent with generalized anxiety disorder.’
  
• Plan: The therapeutic interventions and steps for future sessions.
  
  Example: ‘Begin cognitive-behavioral therapy to address anxiety and develop coping strategies; recommend mindfulness exercises between sessions.’

3. DAP Notes

DAP notes are similar to SOAP notes, but less complex since subjective and objective data are combined in one part. These notes include the following components:

Data: Observations and insights gathered during sessions or from client communication.

Example: ‘The client expressed feelings of loneliness and reported persistent difficulties falling asleep.’

Assessment: The therapist’s interpretation of the data.

Example: ‘The client’s reported symptoms are indicative of moderate depressive disorder.’

● Plan: A detailed therapeutic approach.

Example: ‘Initiate weekly psychotherapy sessions focusing on cognitive-behavioral techniques, and explore the potential benefits of psychotropic medication in collaboration with a psychiatrist.’

4. Focus Notes

Focus notes emphasize specific patient issues or events:

Focus: A comment is attached to a key concern or event.

Example: ‘New in the past month: Frequent panic attacks.’

Data: Client‑reported experiences or observations during the session.

Example: ‘The client reported experiencing three panic attacks in the past week, each lasting 10-15 minutes.’

Action: Steps or interventions taken by the therapist.

Example: ‘Introduced grounding techniques, such as deep breathing and sensory focus, during the session.’

Response: The client’s reaction to the intervention or progress noted.

Example: ‘The client reported feeling noticeably calmer after practicing the second grounding technique.’

5. Narrative Notes

Just like traditional progress notes, narrative notes are unstructured and focus on providing a detailed, day‑to‑day account of client sessions. They provide therapists with significant flexibility, allowing them to add as many details as they want to in that particular note. However, it is also important for a therapist to remain focused on the main purpose of the note and not deviate by providing extra details that have nothing to do with the client’s progress.

Example: ‘The client discussed feeling overwhelmed by workplace stress, citing frequent headaches and difficulty sleeping. The therapist introduced coping strategies, including time management and relaxation exercises, and encouraged their implementation over the coming week. The next session was scheduled to review progress and address additional concerns.’

How to Write a Progress Note: Example

Progress notes can be written in various formats, but they should include key elements such as the client’s subjective experience, objective data, the therapist's impressions, and the plan for further treatment. Below is an example of how to structure a progress note effectively:

Mental Therapy SOAP Progress Note

• Subjective: The client reported ongoing fatigue and heightened anxiety, particularly in social settings. She shared, “I avoid attending social events because they make me feel anxious.”
• Objective: The client displayed signs of agitation, including frequent shifting in her seat, fidgeting with her hands, and avoiding eye contact. Her speech was notably rapid, and her tone was elevated.
• Assessment: While some of the previously introduced coping mechanisms are being used frequently by the patient, some of the client’s symptoms of social anxiety disorder appear to have slightly intensified.
• Plan:
  • Continue cognitive-behavioral therapy (CBT) sessions.
  • Introduce mindfulness exercises for home practice.
  • Schedule a follow-up session in two weeks to evaluate progress.

Progress Notes Template

Here’s a general template for creating progress notes:

[Client Details]

Name of the client, identification number, and date of birth.

[Session Details]

Date, time, duration, location

[Clinical Data Collection]

Record clinical assessment of behaviors, indications or expressions of symptoms, and report the client’s condition.

[Interventions]

Explain various types of therapies or treatment methods used as an action.

[Outcomes & Plan]

Assess the efficiency of the treatment and describe activities in the subsequent stage.

Components of a Good Progress Note

A good progress note is a summary of a client’s session including their condition at the time of the session and the therapist’s management plan. It should be precise and systematic, and offer more than just an account of the client’s progress, which has to be further used to dictate further actions. The following components are important for creating a detailed and effective progress note:

Client Details

A well‑structured progress note should contain the client’s full name, date of birth, and unique identification number. All these details are important for ensuring that the client records are correctly labeled and that they provide full clarity for further progress regarding the client’s treatment, along with fulfilling the legal standards that are required for proper documentation.

Session Details

It is important to note the date, time, duration, and place for documentation purposes. This assists in developing continuity of interactions and helps therapists keep track of their sessions each time.

Client Observations & Clinical Assessment

Your progress note should describe the client’s behavior and the therapist’s observations during the session. For example, ‘The client appeared restless, pacing around the room, indicating signs of agitation.’

Evidence-Based Practices & Future Steps

Integrate evidence‑based techniques and explain the next steps in the treatment process. For example, ‘In addressing social phobia, exposure therapy techniques were applied to help the client confront and manage their phobic reactions.”

Evaluation of Progress Toward Treatment Goals

Assess how the client is progressing toward their goals and whether they are closer to achieving them. For example, ‘The client successfully reduced their cigarette consumption from 15 to 5 per day, showing significant progress toward their goal.’

Treatment Adjustments and Justifications

Explain any necessary changes to the treatment plan, along with the reasons behind these adjustments. For example, ‘The antidepressant dosage has been increased due to the continued presence of low mood symptoms, aiming for better symptom control.’

Session-Specific Interventions and Outcomes

Describe the methods used during the session and their impact on the client’s progress. For example, ‘After a series of hypnosis sessions, the client reported a noticeable reduction in muscle tension, following guided relaxation exercises.’

Summary of Client Feedback and Concerns

Document any feedback from the client regarding their progress or challenges faced. For example, ‘The client expressed frustration with the pace of progress and requested more practical tools to manage their symptoms.’

Follow-Up Plan and Next Steps

Outline the next steps for the client, including any follow‑up sessions and assigned tasks. For example, ‘The client will be asked to keep a coping strategy journal for the next session to track their emotional responses and coping methods.’

Common Mistakes to Avoid in Progress Notes

For writing progress notes, it is important to ensure that they are accurate, clear, concise and complete. There are a few common mistakes that can be made while documenting these progress notes, and here is an overview that will help you avoid them:

Best Practices for Writing Progress Notes

It is important to avoid confusion and misunderstandings to ensure that progress notes are clear, accurate, and relevant to the current treatment plan and future use. Here are some guidelines to help you create effective progress notes:

• Use Clear and Simple Language: Avoid overly technical jargon when writing progress notes. Ensure that the language is clear and simple, so all healthcare personnel can easily understand the content.
• Focus on Relevant Details Only: Include only the most important and relevant details. This not only helps to keep the notes concise and unique but also avoids unnecessary repetition.
• Accurately Document Patient Condition Changes: Progress notes should accurately reflect any changes in the client’s condition, whether positive or negative. This is crucial for determining the appropriate treatment approach.
• Organize Notes Logically and Sequentially: Ensure that your notes are well-organized, following a clear and logical sequence. This makes it easier for other healthcare providers to follow and reference the information when needed.
• Use Standardized Medical Terminology: Use standardized medical terms to maintain consistency and clarity. This ensures that your notes are legally compliant and effective in both clinical and legal contexts.

Benefits of Leveraging Technology for Progress Notes

The technology improves the management of progress notes, supports collaboration among mental healthcare professionals, and helps prevent mistakes. Below is a brief overview of the benefits of leveraging technology for progress note writing.

How to Bill Progress Notes?

Billing progress notes involve selecting the appropriate codes for a session based on the services provided. It is important to have the right code in place for correct billing, reducing the number of mistakes, and avoiding audits. It is recommended to use:

• ICD Codes: To recognize and record diagnoses.
• CPT Codes: For documenting the treatment plans and operations that have been done.

Notes should at all times correspond to what is billed. This minimizes the application of wrong codes and decreases the chance of audit.

Progress Notes with Twofold

Twofold AI Scribe streamlines progress note documentation for mental health therapists, offering efficiency, accuracy, and compliance.

Key Features:

• Template Variety: Includes SOAP, BIRP, DAP, and customizable options to suit various therapeutic needs.
• Customizability: Create or modify templates to fit your workflow.
• Automation: Structured prompts ensure thorough, error-free documentation.
• Compliance: Templates adhere to legal and professional standards.

Benefits:

• Saves time with automated tools.
• Reduces errors and improves accuracy.
• Organizes notes for easy access and continuity of care.

Twofold AI Scribe allows therapists to focus on clients while ensuring high‑quality documentation.

Conclusion

Progress notes play a crucial role in tracking a client’s progress, ensuring compliance with legal and regulatory standards, and facilitating seamless communication within the healthcare team. To maximize their effectiveness, it is essential to document progress notes in a manner that is accurate, concise, and efficient. Adopting best practices and leveraging technology can streamline this process. Beyond supporting the management of health issues, progress notes are also vital for addressing legal or professional matters in a healthcare context, making them an essential component of comprehensive healthcare documentation.