Healthcare professionals must establish and maintain a clinical documenting method that holds them accountable. Progress notes are the perfect way to allow for this ‘paper trail’ where health records can be traced.
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It is of utmost importance for healthcare professionals to establish and maintain a clinical documenting method that holds them accountable. Progress notes are the perfect way to allow for this ‘paper trail’ where medical records can be traced, as the information is concisely and represented for potential review. Clinical progress notes capture every point of communication between patients and clinicians, emphasizing a high degree of transparency.
Progress notes can come in a variety of formats, so long as they identify patients’ healthcare issues from a subjective and objective lens and elaborate on treatment plans. Clinical notes for robust healthcare will work towards progress on a care plan for patients, with their needs prioritized within the practice.
To begin writing progress notes, there are some important factors you should consider.
While there is no one right way to write progress notes, there are undoubtedly valuable aspects that you should include to elevate your quality and conciseness. In particular, using the SOAP method to guide your progress note structure will guarantee you don’t miss any critical aspects. These include discussing four main components:
Many healthcare business platforms, such as Carepatron, also provide templates for clinical documentation through progress notes to guide you along this process. This can be a beneficial tool, but some great tips can aid your progress note writing with SOAP regardless of your choice. We recommend:
Within various disciplines in the healthcare sector, progress notes can look a little different. For instance, progress notes for psychologists can look vastly different to ones for acupuncturists, as they will cater to their specific client needs. To help you better understand progress notes, we have provided an example that can also be used as a progress note template for your practice. These include samples for mental health, as well as for individual therapy, and are structured by the most popular SOAP method.
It can be overwhelming to know where to start with the SOAP method, and so to help you, we have provided the first mental health progress note documentation sample. Mental health is a common discipline to use SOAP notes to document client information and communicate patient data. Because it is a highly flexible format,
this could also be extended to a counseling progress note example for those in counseling specifically. And while all notes can differ, progress notes for mental health may look like the following example.
Subjective
“I feel like I am a failure at work. I work as hard as possible, but I have always been overlooked, and my self-confidence plummets. It’s affecting how I am at home, and I’m beginning to feel miserable.”
Objective
Thomas has a very flat expression and is slumped in his chair. He presents low symptoms and indicates feelings of low self-esteem that are beginning to impair his day-to-day life.
Assessment
This is Thomas’ first session, and he needs ways to communicate his feeling to his work while realizing his self-worth. Failure to do so will likely result in increased depressive feelings for Thomas.
Plan
Thomas will attend further sessions, and we have conducted a plan to work on his perception of self and ways to problem-solve at work. If symptoms do not improve within the next two weeks, a therapist or psychologist will discuss additional treatment and reevaluation.
We have also provided sample therapy progress notes for those in this area to better understand the structure and layout. Once again, this can differ from therapist to therapist, depending on you and your client’s needs and what is most beneficial to you. The four components are relatively flexible with what is written, and SOAP notes can look different for each patient. The following example explores a patient with anxiety.
Subjective
Luke states that he is constantly thinking, saying, “I’m almost always thinking of ‘what-ifs,’ and once I start, it’s tough to get myself out of it. I’ll easily think for hours on end.” Luke claims it affects his day-to-day, with it “affecting my concentration as I can’t focus on university work or my job.” He also explains that it “affects my ability to eat, as I just don’t get hungry.”
Objective
Luke displays significant signs of anxiety, with his symptoms not improving from the past couple of therapy sessions with me. He demonstrates racing thoughts, a lack of concentration, with changes in appetite. His blood pressure levels are higher than average when tracked.
Assessment
Luke is not progressing in current treatment and so will benefit from an amended treatment plan. His symptoms have increased since the past two sessions, and he needs to have a more intensive focus on controlling techniques and monitoring meals.
Plan
I have worked with Luke today on a meal plan where he must check off eating meals at regular intervals, and we have also worked on more techniques involving breath control, mood regulation, and rumination avoidance. If Luke does not improve within the next two weeks, we will consider further or alternative treatment.
Progress notes, while being a legal requirement, are a great way to structure and document client notes and their journey towards good health. They are a perfect way to highlight communication at each point between the practitioner and patient and allow for efficient transparency and traceability.
Creating progress notes also doesn’t need to be complicated, and with the help of platforms such as Carepatron, this process can be made a lot easier. Carepatron not only provides templates for you to work with for your progress notes, but they also offer a variety of features for your healthcare practice. This includes appointment scheduling in one healthcare app, in addition to video conferencing with clients to ensure you are getting the most valuable information. Whatever you may choose, progress notes are a surefire way to ensure success within your healthcare practice and for your patient.
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