Progress Notes For Therapy - Guide

Progress notes are an essential clinical accountability method commonly used by healthcare professionals to show a paper trail of a patient’s medical record. Clinical progress notes highlight a patient’s medical history and capture all communication between clinicians and patients. This allows for information to be transparent and traceable and enables excellent communication across healthcare professionals who may review the records. Therapy progress notes are vital for clinicians to remember essential information and be a legal requirement for healthcare practices.

Regardless of your approach, it is the law to record each patient’s medical history when running a healthcare practice. Every time there is an interaction between a client and their clinician, this needs to be noted, with evidence compiled somewhere. Progress notes are a great way to do so while completely complying with insurance, regulatory, and law policies.   

What should be in a therapy progress note?

Therapy progress notes need to be clear, concise, and understandable for any mental healthcare professional who reviews the material. They are instrumental for patients’ progress and treatment plans in mental health and essential document insight on their therapy journey. While there isn’t one sole ‘right’ way to go about progress notes, multiple aspects are paramount to ensuring informative and effective notes. Some platforms, such as Carepatron, produce software for healthcare businesses that incorporate templates of therapy progress notes to make this process even easier. 

One of the best formats, and most commonly used, is the SOAP format. This progress note type encompasses subjective (S) and objective (O) observations, as well as information concerning assessment (A) and plan (P). 

• Subjective - Refers to information regarding the patient’s experience and feelings and their perception of symptoms. Entirely based on their view and often contains verbatim quotes.
• Objective - Contains factual information concerning the signs of symptoms, such as medical records, examinations, x-rays, and vital signs. 
• Assessment - Combines the previous observations by interpreting them and providing information regarding the patient’s progress.
• Plan - Decides on a specific course of action for the patient and establishes their goals and any amendments required to their current medication and activities. 
  

Another helpful progress note structure, which differs slightly and is not as commonly used, is the BIRP structure. 

• Behavior (B) - Combines subjective and objective observations about the patient regarding their behavior. This includes a mix of quotes, as well as factual and quantified medical information. 
• Intervention (I) - Outlines the steps and methods undertaken to target symptoms and mental health issues. 
• Response (R) - Highlights the patient response to the intervention and current treatment and specifies the patients’ input. ‍
• Plan (P) - Works towards the future with specific goals and courses of action for the patient to improve

To help you make the most of your progress notes, here are some great tips to ensure your patient is understood and receives quality care. 

• Background headers - It is helpful to include essential information such as the practitioner, client, time, and date somewhere on the document
• Diagnosis - This should be indicated such that mental healthcare professionals know precisely what they’re working with
• Patient appearance - It is helpful to paint a picture of the patient by specifying their cognitive functioning, behavior, and demeanor. 
• Subjectivity - It is essential to convey how the client views themself in regards to their feelings, symptoms, and experiences. 
• Safety - Any vital information about the patient’s well-being should be stated.
• Medications - Particularly for psychiatrists, knowing what the patient is being administered can provide important background information.
• Objective information - Tests, examinations, medical records, x-rays, and relevant vital signs are essential to confirm observations.
• Interventions - Documenting treatment currently used, such as CBT, is essential to understand the patient better.
• Treatment plan progress - The objectives of the client should always be considered in progress notes.‍
• Signatures - This allows for HIPAA compliance and provides accountability

Therapy progress notes can be adapted and amended according to their purpose. Because various forms of therapy cater to specific groups and needs, their differences may be reflected in their therapy notes. As a result, we have compiled some examples of therapy progress notes in the standard SOAP format for you to use as templates for your practice. 

Family therapy progress notes

To help, here is a family therapy progress notes example:

Subjective

Sam has indicated that he feels sad often, stating, “I feel low a lot of the day like I just don’t look forward to anything or have any motivation to do anything.” Sam’s father, Andrew, states that Sam is irritable and somewhat detached. He explained, “He still doesn’t want to be involved in a lot of family activities we have, and he gets easily frustrated over trivial matters.”

Objective

Sam has trouble regulating his mood and has anhedonic tendencies with a loss of motivation. He is also somewhat irritable towards his family. Andrew presents an upbeat persona and does not show any signs of depression. He can regulate his mood well, have clear speech, and communicate with clarity. 

Assessment

Sam and Andrew have been attending family therapy for three weeks now. However, it does not seem to be improving, and so this will need to be amended. Sam presents depressive symptoms and does not seem to be making progress. Andrew finds his irritability is becoming more prominent. They will benefit from further treatment.

Plan

Sam and Andrew will continue family therapy with me for next week as usual. I will work with Sam in additional sessions to potentially forward him to a psychiatrist for further treatment if his symptoms do not improve within two weeks. We have worked on a family conflict resolution plan of having family meetings on Tuesdays and family movie nights on Friday. Family meetings will give them the chance to air out grievances, communicate, discuss feelings, and hear each other’s side. If no improvements, we will work towards a new treatment plan. 

Play therapy progress notes

Play therapy progress notes are also a different form of recreation therapy progress notes, which also benefits from being exemplified here:

Subjective

Amelia expressed anger towards her classmates without cause, stating, “I don’t know” when asked why she felt that way. When playing with a giraffe toy roughly, by kicking and punching it, Amelia responded with, “I don’t like it.”

Objective

Amelia presents behavior management issues in being unable to play with the given toys politely. She presents an irritable mood, as she often screams at the toys and finds difficulty regulating her feelings with a lack of speech and communication. 

Assessment

Amelia has attended one previous session at play therapy and displays the same poor control of her feelings. This is as expected with having only one prior session, so it would benefit Amelia to continue. 

Plan

Amelia will see me next week as usual, and if within two weeks there is no change in her behavior, we will need to review her treatment plan. I have worked with her to develop a breathing technique in conjunction with others, to modify and help her understand her behavior in the meantime. 

Psychotherapy progress note

Provided is a psychotherapy progress notes template, with progress notes for individual therapy. For more information concerning psychiatry note software, many platforms, such as Carepatron, offer additional templates. 

Subjective

Jack is experiencing intense urges to drink and constantly thinks about it, stating, “Most of my day, I think about how much better I’d feel if I just had a few drinks.” He says that despite these feelings, he manages to remain sober. “I think of my kids, which helps a lot with immediate urges, and I know I have to be sober for them.”

Objective

Jack has shown up to therapy with sober signs. He has been engaged, present, and alert, and his concentration is improving. He manages to control his urges well so far and abstains. His wife Mandy attested to his behavior, saying he has stayed sober and regulates his mood well. 

Assessment

Considering Jack’s substance abuse experience and how it is a moderate case, it seems fit for him to continue seeing me weekly for therapy. We have worked through controlling and modifying techniques which seem to be working well. Despite his strong urges, he is handling them well. 

Plan

Jack would benefit from seeing me next week as usual and continuing to review and note his progress. He seems to be making significant improvements, and if he shows signs of relapsing, we will need to create a new treatment plan. Perhaps concerning group therapy.

Therapy progress notes, not only are a legal requirement for mental healthcare practices, but they are a great way to reference, record, and analyze patient information. Hopefully, you have more knowledge of the various aspects of progress notes to provide the best care for you and your clients. 

Many healthcare businesses incorporate progress notes into their workflow, and with the correct application, such as Carepatron, this process can be made even more accessible. Carepatron is a place for you to compile essential clinical documents online in a safe, secure, and highly confidential way. The progress notes you supply will be encrypted for utmost protection, with embedded progress note templates provided for your convenience. 

Despite different formats and whatever you choose for your practice, keeping in mind your clients' goals is of great importance. Progress notes need to be easily understood, and with careful consideration, you can design the best treatment plans and records for your patients. 

Further reading:

• Fundamentals of the Legal Health Record and Designated Record Set