Counseling mental health progress note documentation sample

Mental health progress notes… 

What are they? 

And why does everyone keep talking about them? 

Well… As a healthcare professional, remembering details about every session can take a tremendous toll on your mental load (and health 🥴), no matter how good your memory is. Writing everything down provides an important reference point for you and ensures you can build rapport with each client by remembering essential details about each session. 

So, progress notes are basically the best tool you'll have to be a great practitioner. Not to mention they're legally required in most countries. 

Still confused! Not to worry.

That's why we have this article! Read to the end, and you'll be a progress note Pro ☺️

What are progress notes? 

Client notes are at the core of any health professional's practice.

They are essential documents created by the practitioner to document and maintain a client's medical records. They provide a paper trail of a client's treatment history and ensure that communication between clinicians within the healthcare sector is seamless and traceable. In addition to this progress, notes are legally required each time there is an interaction between client and practitioner to provide a record and to ensure best practice within the practitioner community. Any competent and compliant clinician will keep a detailed set of progress notes for each client they see.

How can these progress note templates allow you to create effective progress notes?

Progress notes are a contract between the client and their clinician. They are where treatment goals and plans can be discussed and decided on before they are put into a document to track the treatment progression. 

Without the right formula writing progress, notes can be a lengthy process. Using a format such as SOAP notes means that the product is far more informative and concise. SOAP is an acronym for subjective, objective, assessment, and plan. It helps ensure that each part of the therapy note has a purpose and that no critical details are missed from a progress note.                                                                       

In addition to a formula such as SOAP notes, we've provided you with some templates to outline what you can expect to see ineffective progress notes… think of these templates as 'progress note goals' kinda like the Obama's are to 'relationship goals' but maybe a little easier to achieve...

Counselling progress note template & examples

For counselors, progress notes often take a journal-like form, focusing on the process between therapist and client and the counselor's own thoughts and feelings in the work. 

Click here to see an example. 

Psychotherapy progress note template & examples

Psychotherapy progress notes are notes taken by mental health professionals for the purpose of documenting or analyzing the content of a conversation during a therapy session. 

Click here to see an example. 

Medical progress note template & examples

Medical progress notes are the part of a medical record where practitioners record details to document a patient's clinical status or progression during the course of hospitalization or over the course of outpatient care. They're a bit different.

Click here to see an example. 

Patient progress note template & examples

Patient progress notes are the component of the patient's record in which you record notes about the interaction you had with them, their reason for visiting, examinations performed on them, medications prescribed on the day, and other relevant details. 

Click here to see an example. 

Nursing progress note template & examples

Nursing progress notes are the records kept by nurses during their interactions with each client. These notes help health professionals keep track of the medications and care a patient receives and allow for the patient's medical records to be as up-to-date as possible.

Click here to see an example. 

Doctor progress note template & examples

Physicians record their notes concerning the progress or lack of progress made by the patient between the time of the previous note and the most recent note. In addition to this, doctor's progress notes also describe the patient's condition and the treatment given or planned."

Click here to see an example. 

Group therapy progress note template & examples

Group therapy notes have two components. The first part of a group therapy note is the group summary. This includes basic information on the group, such as; the group name, main topic(s) covered during the session, interventions implemented, and the schedule. In the second, individualized section, it is important to document how the client engaged within the group. Include information like their level of active engagement, contributions, and reactions.

Click here to see an example. 

Do's and don't when writing progress notes & examples

Here are some top tips to make sure your notes are up to scratch; 

• Be specific and concise in your progress notes. No one has time to write or read novels in the healthcare sector. 
• Prioritize your notes. Letting them build-up will only make the problem worse...
• Using a template such as SOAP to help you  
• Capture and store your progress notes on a secure practice management platform
• Voice transcription. Yes, it's a thing. Click here to find out how you can use it!
• Focus on the patient's problem: Progress notes are designed to help you manage and organize your treatment plan, don't complicate things! 
• Consistency: Using a SOAP note template will help you and your team maintain consistency of the format, length, and abbreviations

Some Common Mistakes to Avoid:

• Repeating yourself: In the Assessment section, do not rewrite what you stated in the Subjective or Objective sections.
• Writing too many notes in the session: Give your client all of your attention; capturing some brief notes as you go focusing on quotes is more than enough.
• Judgmental statements: Ensure you use professional language in your notes. 
• Avoid acronyms and abbreviations: It's best to minimize acronyms and abbreviations to prevent misinterpretation. 

How do you write a mental health progress note?

What should a mental health note include?

How do you document progress notes?

What is the most recommended format for documenting progress notes?