Andrew’s Guide to Fantastic Progress Notes
Documentation takes an escalating priority in the ever-developing therapy world. I hear many therapists say they spend just as much time writing documentation as they spend with clients. And yet, most also tell me they received little to no training in documentation during graduate school, especially in proportion to how important it is to their work. This is a shame, as documentation serves a key place in crystalizing therapeutic care. We learn how to listen well but not how to document our listening, and we miss this essential skill.
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I felt discouraged in the therapeutic profession because of the drudgery and lack of clarity around progress notes. I am comfortable with ambiguity, but not when my license is on the line. Furthermore, I did not know if my progress notes were truly serving my clients well.
To leave that murky situation, I took time to research optimal methods of progress note creation. I read books, articles, called insurance companies, talked with other therapists, and attended trainings: all to develop a streamlined process. I created a series of ten steps for myself and I want to pass on that same carefully cultivated process to you so that you will not struggle with progress note ambiguity like I did. By the end of this blog article, you will have the knowledge to write high quality progress notes with ease.
What Are Progress Notes?
Progress notes, sometimes called session notes, are an official part of the clinical record which records the client progress and active treatment. These records link directly to, but are distinct from, the treatment plan. A clinician uses progress notes to monitor a client’s progress through a treatment plan. Progress notes are meant to be factual, necessary, and part of the clinical record. There are legal expectations for this as courts can subpoena progress notes when needed. In addition, clients can request copies of their progress notes.
This contrasts with a notation type called psychotherapy notes or process notes. Psychotherapy notes are meant to be a separate entity from progress notes where a clinician documents impressions or hypotheticals. They can even be written in shorthand. While these notes are more confidential, courts can still subpoena them. Process notes are easier to write, for me, because I rarely show them to anyone else. I hold progress notes to a higher standard.
As I write this, it is important to include that my marriage and family therapist license is from the state of California in the United States. As such, my advice best pertains to that area. In my experience, California law leans more in favor of clients holding privilege of their notes than clinicians or courts, but it otherwise represents a suitably high standard of treatment care. I have meticulously researched while creating my steps, but applicability will vary from one area to another area. As always, a clinician’s notes are their responsibility.
Why Use Progress Notes?
Besides the fact that progress notes are legally mandated, there are other reasons to keep high quality progress notes:
- In the case of a therapist transition, such as if a therapist dies or a client moves away, progress notes help a future mental health worker quickly resume care of a client.
- Insurance companies may rely on progress notes to assure the adequacy of care provided to their members.
- Progress notes provide an increased layer of communication in community health contexts.
- Courts may examine progress notes to establish custody or to assign blame.
- Clients are entitled to copies of their own medical record (should that not be a detriment to their care).
- Progress notes benefit a therapist’s memory and facilitate consistent care.
What about Progress Note Formats?
Before I get to my ten steps, let me differentiate them from note formats like S.O.A.P. (subjective, objective, assessment, plan) notes or D.A.P. (data, assessment, plan) notes. Note taking formats provide a standard structure that is easily intelligible to other therapists and other professionals. A nurse (familiar with SOAP notes) can look at a social worker’s SOAP notes and easily distinguish the various sections to find the prescribed interventions. For that reason, these formats are often found in community mental health settings where multiple disciplines work in concert.
While the consistency is helpful, note formats necessarily inform little about note content. A nurse notices different things than a marriage and family therapist but they can both use the same note format. What specifics of a psychotherapy session need to be placed in the different zones of a note format? What is supposed to go into the plan step or what data, out of everything that happens in the session, goes into the data section? We need more clarity for a high-quality progress note than just a format.
My ten steps can easily fit into any type of note format, just change the order around depending upon the format you want to use. So, without further preamble, here are the steps.
Step 1: Presentation
I start a progress note with an assessment of my client’s presentation to the session. With the question, “how do they appear in the session?” as my guide, I conduct a quick mental status exam based upon my observations of a client’s mental state.
My introduction into the mental health world was at a psychiatric health facility. At that time, I found it invaluable to have a constant understanding of a client’s mental state. While I work at a counseling center now, I still find recording my client’s mental status helpful. It allows me to track themes and patterns from week to week and helps me to spot abnormalities. I also document my client’s timeliness to the session as that helps me establish a behavioral baseline.
For telehealth sessions, I make certain to document matters like the client’s location and their suitability for telehealth. While usually mundane, the particulars can easily become critical. After all, the necessity for an involuntary psychiatric hold can arise just as easily in a telehealth session as in an in-person session. Furthermore, I want to reassure myself, and those that look at my notes, that I am being cognizant of that reality.
Step 2: Symptomatology
The next step is identifying the client’s symptomatology. This is a crucial step to the progress note because it justifies the client’s reason for being there and provides me with valuable information for diagnosis, treatment, and treatment progression. This section also informs the progress of treatment later in the progress note.
I fill out much of this step with symptoms lifted directly from the DSM-5, but you can supplement with quotes from the client. You might use language from any of the superfluous number of psychological assessments available to you. No matter what method you use to assess these symptoms, record them in a succinct list.
The symptomology step is critical for assessing the client’s level of impairment and distress caused by their symptoms or diagnosis. (In Chronicler, this portion is divided into its own step called “disruption” for design purposes). It includes documenting how the client’s functioning is affected in different domains of life, such as family, work, or wellbeing. By recording the disruption level, we can demonstrate the need and urgency for treatment and monitor the progress and outcomes of our interventions.
Step 3: Diagnosis
I simplified my diagnosis step because my client’s diagnosis already exists in my treatment plan. In this step, I simply make certain that I am on track. Generally, I list the syndrome or diagnostic category into which the symptoms most likely fall. I stick with the chapter headings of the DSM-5 as I always know I will have backup for that classification label.
If a change takes place in my thinking or I notice a new diagnostic feature, I will document in the progress note that I’m updating my treatment plan. Then, I reflect the specific diagnostic code in the treatment plan instead of in the progress note. My reason for keeping the progress note free of the exact diagnosis is three-fold:
- Diagnostic labels best fit at the beginning of a stage of treatment, not on an ongoing basis.
- I do not want to slow down the generation of a progress note by having to evaluate the specific criteria each session.
- Diagnostic labels in the DSM-5 benefit research more than clients directly, and I want my progress notes geared towards the benefit of my client.
Step 4: Safety
In the fourth step, I assess the status of my client’s safety. I routinely observe and ask my clients about their safety and wellbeing. I want to know whether they are having passive suicidal thoughts without intent or whether there is intent. If there is intent, do they have a plan or timing to it? What resources do they have to cope with such a situation if it were to come up? I would document any necessary safety assessment and planning that took place.
Step 5: Topics
Progress notes are not a verbatim record of everything that was talked about in the session. However, it is important to include the basic topics discussed in the session. This helps to keep track of the focus of treatment and make certain that therapy is lining up with the client’s goals. I record general topics such as: family related, friend related, work related, etcetera. I keep specifics out of this section and, instead, put them into my psychotherapy notes. This keeps the progress notes functioning on a clinical level instead of being a diary of a client’s week, a mistake I see all too often.
Step 6: Interventions
The intervention step is the most significant part of the progress note. This step records the actions taken during the session. It lets insurance companies know your excellent work and informs potential future therapists of already utilized techniques. Because of this, interventions should match up with your treatment plan but be more specific.
I feel immense frustration when I see this portion of a progress note woefully underrepresented. Many progress note examples simply list out the modality of an intervention like “DBT” but this is negligent, in my opinion. As therapists, we need to provide concrete details of interventions in the session. Labeling an intervention such as “CBT techniques” leads to ambiguity around which techniques were used.
Instead, I include more substantial, meaningful statements. I broke down every treatment modality that I use into simplistic statements so that I know exactly what I have done within a modality. Keeping track of specific techniques, rather than just the modality, increases my efficiency in the session because I can move fluidly to the next one. Even more emotional based modalities such as accelerated experiential dynamic psychotherapy or emotion-focused therapy have clear-cut techniques.
Here are some samples of specific interventions:
- “role playing the schema activation in the session”
- “summarizing the client’s contradictory views”
- “planning and reviewing healthy methods of mental distraction”
- “exploring a part’s desires for client and its role in those desires”
These statements allow anyone to notice the precise interventions rather than guessing. It takes longer to do this than simply naming a modality, but I find it induces accuracy and quality. Furthermore, during the session, I actively know what technique I am using and how it is helping my client.
Step 7: Strengths
Modern therapy has seen a resurgence of focusing on the positive. Modalities like solution focused or narrative therapy often rely on the strengths of a client. In truth, most of a client’s progress comes from their own resources and strengths, not the brilliant deductions of a therapist. While I might not gain any points from an insurance company, I like to include my clients’ strengths as I see them. This is a constant reminder to me to play to my client’s strengths and to encourage them to utilize their own resources. I prefer to include this in my progress note rather than my psychotherapy note because I want my work to reflect that I am always focusing on my client.
Step 8: Response
In the response step, I record my client’s reaction to these interventions and to the session itself. This practice grounds my treatment in the client’s reality and helps filter useful interventions from unproductive ones. I routinely assess my client’s satisfaction in the session and record those responses as well. Because I have made thorough records of my interventions, I can speculate in the psychotherapy note section about what interventions might be more effective in order to enhance my client’s experience. I often take this information and can adjust my treatment plan accordingly.
Step 9: Progress
As I mentioned before, it is crucial to understand your client’s progress towards their goals. In my progress step, I document progress made towards treatment goals or projects. I find it humorous that the step from which progress notes derive their name is often the shortest step. This section is quite straightforward, but I review it often because it helps me understand changes that are needed to improve my client’s experience.
Step 10: Tasks
In the tenth and final step, I insert tasks that I need to complete before the next session. To clarify, I include items that the client needs to complete in the intervention step; the tasks step is just for my tasks. For instance, as is often the case when I work with teenagers, I document tasks such as contacting the client’s parents for further information. I also document tasks such as consulting with my colleagues. This increases my treatment plan’s fluidity and justifies the other work I do during the week.
There are a few outstanding bits of information that, while they don’t come up every session, warrant space in a progress note. These subjects are frequently administrative in nature. I document these essential topics when they arise in treatment.
It is a legal and ethical obligation to discuss the cost of treatment up front with the client. I document this and other initial discussions about therapeutic procedures. Administrative issues are not limited to the beginning of therapy, however, so I include those discussions whenever they occur. This helps protect me against claims that I have not been forthright around my fees or other administrative practices. Administrative issues are not the sexiest part of therapy, but they are a necessary component of a clinical record.
Similar to administrative issues, I document informed consent and other types of disclosures to the client. These always occur before and at the first meeting with a client, but they may also occur during the normal course of treatment. I like to reiterate disclosures occasionally during the therapeutic process so that there are no surprises for a client even months down the road. This provides me with coverage and superior quality care.
As I mentioned before, I first began my clinical experience working at a psychiatric health facility. While there, I gained an increased appreciation for the phrase, “write it down or it didn’t happen.” I take it upon myself to write in-depth progress notes because I want supporting evidence to the care that I provide my clients. My progress notes tangibly manifest the respect I have for my clients and my therapeutic practice.
These ten steps create a framework for superior notes: notes that walk the careful boundary between sufficiency and timeliness. Progress notes must hold appropriate information to aid in client care. At the same time, there is a practical component of progress notes; they need to be concise, routine, and written fast enough that I can still use the bathroom in between client hours. Using these ten steps regularly keeps my notes thorough and practical.
About two years before my writing this, I teamed up with a friend of mine to make these ten steps even faster. My progress notes are both high-quality and quick because of a web-based program we designed and titled, Chronicler. Chronicler contains more than 600, easily searchable, statements to speed up progress note creation. Now, I can wholeheartedly chronicle my client’s journey to success in an efficient manner.
Philip and I made certain Chronicler incorporated these steps and everything that they stand for; quality, sufficiency, and timeliness. We wanted to raise the bar on progress note creation for therapists so that it was in line with the duties of other medical disciplines but also reduce the burden. Chronicler brings me through these ten steps in 3 minutes, which lets me have high-quality progress notes without sacrificing my time.
Whether you join us on our journey to revolutionize the therapy field or not, these ten steps will serve you well in your practice as you document your clients’ experiences. As I end this article, I welcome you to richer, more in depth progress notes.
See Chronicler in Action
Music credit: https://www.bensound.com/