How to Write a Mental Health Progress Note

The art of writing progress notes is an essential part of a therapist’s toolkit. In this article, you’ll learn how to write a progress note, the different types of progress notes, and what should be included in each section. We’ve also included several progress note examples to help you get started.

There are multiple ways to write a progress note, and each practice typically has their own preferred format, so you’ll need to take this into consideration when writing your note.

What is a therapy progress note?

A therapy progress note is a written record of a patient’s treatment session, documenting their progress, challenges, and goals. These notes serve as a crucial tool for mental health professionals to track their clients’ journey and ensure continuity of care. By maintaining accurate and detailed progress notes, therapists can monitor their patients’ symptoms, assess the effectiveness of treatment plans, and make informed decisions about future interventions.

Progress notes typically include a brief summary of the session’s main topics, the patient’s current emotional state, and any significant changes or developments since the last session. Therapists may also record observations about the patient’s behavior, thought patterns, and interpersonal relationships. Additionally, progress notes often outline the therapeutic techniques employed during the session, such as cognitive-behavioral therapy (CBT) or dialectical behavior therapy (DBT), and the patient’s response to these interventions.

Mental health progress notes serve multiple purposes beyond guiding treatment plans. They can be used to communicate with other healthcare providers involved in the patient’s care, such as psychiatrists or primary care physicians. Progress notes may also be required for insurance reimbursement, legal documentation, or quality assurance purposes. Well-written and comprehensive therapy progress notes contribute to better patient outcomes by ensuring that mental health professionals have a clear understanding of their clients’ needs, progress, and treatment history.

How to write a mental health progress note

The most effective way to write a progress note depends on what makes you feel most comfortable. Many clinicians prefer to take short notes during a session, then write a more detailed summary afterwards. Others will take no notes at all, and write up their notes from memory.

Regardless of your preferred method, it’s essential to write your progress notes as soon as possible after the therapy session. This ensures that the details are fresh in your mind, reducing the likelihood of forgetting important information or observations. If you choose to take notes during the session, be sure to keep them brief and unobtrusive, as excessive note-taking can be distracting and may hinder the therapeutic process.

Here are some general tips:

Take brief notes during the session: Jot down key points, observations, and insights as they arise during the therapy session. This will help you capture important details while they’re fresh in your mind. However, be mindful not to let note-taking disrupt the flow of the conversation or your engagement with the client.
Use clear, concise language: When writing your progress notes, use simple, straightforward language that is easy to understand. Avoid jargon or overly technical terms, and be specific in your descriptions of the client’s symptoms, behaviors, and progress.
Focus on the client’s presenting concerns: Prioritize the issues and challenges that the client brings to the session. Document their primary symptoms, the impact on their daily life, and any changes or improvements since the last session.
Include objective observations: Record observable behaviors, body language, and other relevant details that provide insight into the client’s emotional state and progress. Be sure to distinguish between objective observations and your own subjective interpretations.
Highlight interventions and treatment plans: Describe the therapeutic interventions you used during the session and how the client responded to them. Outline any updates or modifications to the treatment plan based on the client’s progress or changing needs.
Maintain client confidentiality: Always adhere to privacy regulations and ethical guidelines when writing progress notes. Use initials or redactions instead of full names, and avoid including unnecessary personal details.
Utilize an electronic health record (EHR) system: Many mental health practices now use EHR systems to streamline documentation and ensure secure storage of client records. Familiarize yourself with your organization’s EHR and use it consistently to add and update progress notes.
Review and proofread: Before finalizing your progress notes, take a moment to review and proofread them for clarity, accuracy, and completeness. Ensure that your notes are free of errors and that they effectively convey the key points from the session.

What to include in mental health progress notes

What you include in a typical progress note will differ based on the requirements of your practice, governmental regulations, and insurance company. However, most progress notes will include the following:

Date and time of the session
Client’s name and identifying information (e.g., date of birth, case number)
Therapist’s name and credentials
Type of session (e.g., individual, group, family, or telehealth)
Client’s current mood and affect (e.g., “anxious,” “depressed,” “cheerful”)
Brief summary of the session’s main topics and themes discussed
Client’s self-reported symptoms, concerns, and any changes since the last session
Observations of the client’s behavior, appearance, and overall functioning
Assessment of the client’s progress towards treatment goals and objectives
Specific interventions, techniques, or therapeutic approaches used during the session
Client’s response to interventions, feedback, and any insights gained
Any changes in medication, treatment plan, or referrals made
Risk assessment, including suicidal ideation, self-harm, substance abuse, or violence
Plans for future sessions, homework assignments, or action items
Collaboration or consultation with other healthcare providers or family members (if applicable)

Remember to write objectively, focusing on facts and observations rather than personal opinions. Use clear, concise language and avoid jargon or abbreviations that may be unclear to others. Maintain client confidentiality by storing progress notes securely and following HIPAA guidelines.

It’s crucial to maintain professionalism and accuracy in your documentation. Be aware that progress notes could be requested by your patient, or subpoenaed by a court of law. For this reason, many therapists choose to omit certain details from their progress notes to protect the client’s privacy, maintain trust in the therapeutic relationship, and prevent misinterpretation or misuse of the information. They may summarize general themes or issues discussed without providing specific details, and avoid including personal thoughts, feelings, or speculations about the client that could be misconstrued if taken out of context.

The decision of what to include or exclude from progress notes is a matter of professional judgment. Therapists must balance the need for thorough documentation with the importance of protecting client confidentiality and maintaining the integrity of the therapeutic relationship.

The different types of progress notes

There are several different types of progress notes used in mental health settings, each with its own structure. The three most common types are SOAP notes, DAP notes, and BIRP notes.

SOAP Notes

SOAP notes are a widely used format for progress notes. SOAP stands for Subjective, Objective, Assessment, and Plan.

Subjective: This section includes the client’s reported thoughts, feelings, and experiences.
Objective: Here, the therapist records observable behaviors, actions, and appearance of the client.
Assessment: The therapist provides their professional interpretation of the client’s situation and progress.
Plan: This section outlines the next steps in treatment, including any changes to the treatment plan or goals.

DAP Notes

DAP notes are another popular format, focusing on Data, Assessment, and Plan.

Data: This section includes both subjective and objective information, combining the first two sections of SOAP notes.
Assessment: Similar to SOAP notes, this section is for the therapist’s professional interpretation and analysis.
Plan: The plan section outlines the next steps in treatment and any updates to the treatment plan.

BIRP Notes

BIRP notes stand for Behavior, Intervention, Response, and Plan.

Behavior: This section focuses on the client’s specific behaviors, thoughts, and feelings during the session.
Intervention: Here, the therapist describes the techniques, strategies, or interventions used during the session.
Response: This section notes the client’s response to the interventions and any progress made.
Plan: As with other formats, the plan section outlines the next steps in treatment and any necessary changes to the treatment plan.

While SOAP, DAP, and BIRP notes all serve the purpose of documenting a client’s progress in therapy, each type has its own unique structure and focus.

When deciding which type of progress note to use, consider your agency’s requirements, your personal preferences, and the specific needs of your clients. SOAP notes may be more suitable for complex cases that require detailed documentation, while DAP notes can be efficient for straightforward sessions. BIRP notes offer a balance between the two, capturing essential information without being overly lengthy.