An introduction to progress notes
Progress notes are an efficient form of clinical documentation that are written by healthcare practitioners following a session with a patient. Not only are they a legal obligation, but progress notes cover all relevant information concerning a patient’s condition. Used by over 80% of healthcare physicians, progress notes outline subjective and objective notes on a patient’s current health, in addition to assessment plans and a finalized course of action for treatment. Like systematic electronic health records, progress notes are a helpful way to quantitatively track patient progress, while also sharing information across third parties and healthcare providers. Their concise and universal format makes them a great practice to implement within your clinic.
How do you write a progress note?
There are various ways to write a progress note, and each method can bring about its own benefits. There are three common progress note methods, which are listed in order of popularity amongst healthcare professionals:
- SOAP - SOAP notes are the most common progress note method, and they separate notes into four categories: subjective, objective, assessment and plan. Healthcare professionals prefer this method due to their wide coverage of critical healthcare elements and how they allow for a representation of a client’s condition in a concise way.
- BIRP - While these are similar to the SOAP structure, BIRP notes focus on behavior, intervention, response, and plan. They focus more broadly on the assessment section by including an intervention part, and how the patient has been responding to the current treatment.
- DAP - DAP notes only cover three areas; data, assessment, and plan. Because the data section merges subjective and objective observations, some healthcare professionals may have to spend time deciphering what is useful for certain situations.
Your notes should follow one of these formats and should be written concisely and consistently. Avoiding vague language and excessive wording ensures professionalism in your writing and an easier translation of critical details to fellow healthcare professionals. To guide you, there are healthcare software platforms that provide online resources to make progress notes easy to understand, which may be beneficial.
What should be included in a progress note?
Depending on your healthcare practice and your specialty, progress notes can look a little different across clinics. However, there are some vital components that will ensure you are producing high-quality notes that any healthcare professional can easily understand, including the following:
- Personal information - You need to include the patient’s ID, name, physician’s name, as well as the date and time of the session.
- Patient description - You must describe the presentation of your patient, which includes body language, behavior, attitude, and cognitive functioning. This must be objective, so you should refrain from making personal comments, and inhibit personal biases or perceptions that could cloud your judgments.
- Symptoms - Include what the patient is feeling in regards to their symptoms, as well as evidence to support signs of symptoms.
- Data - Data should be provided to back up your claims regarding how the patient presents themselves, and these may include vital signs such as glucose levels, blood tests, physical activity, sleeping patterns, or x-rays.
- Intervention and treatment - You should state the current treatment plan of the patient, their response to it, and any relevant amendments. The treatment plan should facilitate the success of patient goals, and cultivate improvements for the patient, which may concern referrals.
- Plan - Every progress note should conclude with a detailed plan regarding the next steps of treatment. This will include the details of any upcoming session and relevant short and long term goals for the patient.
How to write good psychotherapy progress notes
When it comes to writing clinical documentation, every practitioner will have their own preferred methods. That being said, there are certain strategies you can employ to help improve your documentation process.
General tips for writing psychotherapy progress notes
- Timeliness: It doesn’t take long for clinical documentation to pile up. The best way to ensure you stay on top of your progress notes is to write them at the end of each session.
- Tools: Fortunately, there are an abundance of resources available to make the clinical documentation process easier, including note templates and voice-to-text transcription software. Making the most of these will save you a lot of time without compromising the quality of your notes.
- Conciseness: Although it can be tempting to try and capture every detail of your sessions, you should always remember that being concise is key. Avoid using lengthy or overly wordy sentences and stick to the point.
- Avoid abbreviations: Progress notes are frequently shared between different providers. In order to ensure your notes are easily read by others, you should avoid abbreviations that aren’t universally understood.
How to write psychotherapy progress notes faster
Clinical documentation takes time. While it’s important that you maintain accuracy for all of your progress notes, here are a couple of tips to help you speed up the process:
- Shorthand: During your sessions with clients, it can be a good idea to write shorthand notes. You don’t want to risk getting distracted by recording lengthy details, but jotting down a few important notes will ensure the information stays fresh in your mind. When it comes time to translate these into progress note form, you’ll find the process occurs much faster as you’ve already recorded some of the information.
- Software: As we mentioned, there are a wide range of tools available to help with the clinical documentation process. One of the most effective of these is software. Different platforms have been designed to streamline the documentation process: these are typically integrated with note templates, voice-to-text transcription and secure storage capabilities. Utilizing these tools will make writing progress notes much easier, saving you countless hours of valuable time.
Examples of psychotherapy progress notes
Using the above tips will allow you to improve your documentation skills and create effective and accurate progress notes. So you can visualize what this looks like, we’ve included an example of a psychotherapy progress note, using the SOAP format:
Subjective: Angela says she has been “feeling better”. She has been sleeping between “6-7 hours a night” and “eating at least 3 meals a day”. Angela reports compliance with medication.
Objective: Angela was attentive and engaged during the session. Angela was neatly dressed and well groomed. She presented with normal speech and a full affect.
Assessment: Angela is responding appropriately to treatment. Compliance with medication has contributed to improved symptoms. Angela is implementing routine into her everyday life as discussed in previous sessions. Angela will continue with her prescribed medication.
Plan: Angela to continue weekly sessions, with the next scheduled for 3pm on 06/08/2022. Angela has set a goal to introduce regular exercise (3 times a week) into her routine.
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Progress notes template + Example
To help you visualize the best progress note structure, we have provided a progress note example and template that you can implement into your healthcare documents. Using this information will ensure you are meeting HIPAA standards, whilst guaranteeing the production of concise notes that can be understood by a variety of healthcare professionals. Given that the SOAP format is most widely used, this will be the basis for the example psychiatric progress note.
Subjective
- This section aims to capture patient data from their experience, and focuses on their needs, symptoms, and preferences.
- This may incorporate direct statements that are cited word-for-word.
- The subjective segment permits clinicians to archive firsthand what the patient feels and allows the inclusion of commentary from relatives, friends, and other contacts.
- Experts who audit this data can have a more clear picture, with significant knowledge into the credible experience of the client.
- Note that you mustn’t paraphrase, provide irrelevant information, or inject personal comments without supporting evidence. Because it is the subjective patient experience, they should be largely guiding this section.
Jennifer reports a low mood throughout the day, in addition to a loss of interest and motivation. This is highlighted in her statement, “I feel sad. I used to enjoy exercising, but I find it so hard to motivate myself. I don’t care, to be honest. That feeling never goes away throughout the day or the week.”
Objective
- In this segment, you should aim to incorporate factual and verifiable observations, in addition to quantifiable assessments, tests, and vital signs.
- You should be confirming or rejecting symptoms presented in the subjective section with medical evidence such as x-ray results and examinations.
- What is seen here might possibly go against or supplement what is exhibited in the abstract perceptions, and you must recognize the difference.
- Objectivity is also key, meaning that you should forgo general proclamations without supporting proof. Ideally, you should utilize proficient language that limits the danger of distortion, as this patient data needs to be imparted plainly to other medical services experts.
Jennifer has slow communication and slow motor movements. Her speech suffers from a flat affect with little expression in her voice, which is also mirrored in her facial movements. She appears to express anhedonic thoughts.
Assessment
- The assessment section in the SOAP format empowers medical healthcare experts to survey the subjective and objective observations to facilitate the patient’s progress.
- Assessment serves as a systematic analysis of the patient’s current health condition and allows a more exact portrayal of the diagnosis.
- The evaluation takes into account a methodical examination of the fundamental issue, any hidden or related issues, and empowers the specialist to have a 'greater picture' impression of what is happening.
- This approach works towards a treatment plan by evaluating how the patient is doing with their current resources, and whether there should be any changes. It is critical to take note of their analysis, their advancement, and any progressions in medicine or treatment in a professional manner that avoids repetition from previous sections.
Jennifer has Major Depressive Disorder (MDD) and is currently seeking CBT. She came in today with the intensification of previous symptoms, as shown by her disengagement from previously enjoyed activities. This indicates the presence of MDD, and more intensely than last week, and therefore, will benefit from further treatment.
Plan
- As the final section, the plan involves the examination of the assessment and analysis of observations to formulate the next course of action. Doing so will establish a direction for the patient, and recognize the next stage for them to continue pursuing their medical goals.
- This might mean proceeding or altering the current treatment plan or setting up another one, which could mean changes in activity, drug, or objectives. Including the treatment that is presently given provides the rationale behind the choice of administration, and noting the patient’s current response is also highly beneficial.
- It is also useful to record when the next session is, what the patient will be working on once out of the clinic, as well as any reconsideration and evaluation of medical objectives.
- While it is helpful for you as a clinician to have a bearing on your discussion, it is equally significant for the patient to understand what is required of them to work towards alleviating symptoms and treating their condition.
Jennifer is undergoing CBT to alleviate symptoms of MDD. She is not responding well, and so Jennifer would benefit from seeing a psychiatrist to be prescribed SSRIs, if appropriate. As usual, Jennifer is to continue seeing me in therapy next week. I have also discussed with Jennifer new behavioral techniques to reduce some of her prominent symptoms presented today.
Progress note templates
To further assist your clinical documentation process, here are 3 downloadable progress note templates:
- Basic SOAP note template: Sometimes, simple is best. This template is separated into the four SOAP note sections, helping to guarantee consistency across your documentation.
- SOAP note template: This is another format for a SOAP note that includes a diagram. Best suited for physiotherapists and massage therapists.
- DAP note template: This template uses the DAP format, which separates progress notes into data, assessment and plan. You may find that this layout suits your documentation preferences more than SOAP.
What is the most recommended format for documenting progress notes?
While there are various progress note structures and methodologies you can incorporate into your healthcare practice, you must consider what works best for you. Different practices have different healthcare goals and needs, therefore, you need to research, trial, and select a format that is in your best interest. While SOAP notes are the most common, and most widely recognized, other structures may be easier and more efficient to use. Clinical management software, such as Carepatron, can support you in this process by providing progress note templates and examples relevant to the specialty of your practice. Understanding and mastering the knowledge of progress notes can elevate the quality of your practice, and ensure you provide the highest standard of care for your patients.
Further reading:
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