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                                                                        Medical	progress	note	template	pdf
  Clear,	concise,	and	accurate	therapy	progress	notes	are	beneficial	to	practitioners	and	their	clients.	They’re	instrumental	in	monitoring	a	patient’s	progress,	the	efficacy	of	their	treatment,	and	helping	professionals	understand	their	patient’s	personal	experiences.To	be	helpful	and	informative,	though,	progress	notes	in	mental	health	need	to	follow
  some	guidelines.	In	this	overview,	we’ll	introduce	their	key	elements,	a	step-by-step	guide	to	writing	therapy	progress	notes,	and	some	of	the	best	therapy	software	you	can	use	to	create	excellent	progress	notes	efficiently.Before	getting	started,	we	recommend	trying	Quenza,	our	therapy	notes	software	for	e-mental	health	practitioners.Quenza	is	a
  complete	suite	of	blended	care	tools	that	includes	everything	you	need	to	make	and	store	clear,	professional	therapy	progress	notes	on	a	HIPAA-compliant	platform.Progress	notes	are	clinical	notes	made	by	psychologists,	therapists,	clinical	counselors,	psychiatrists,	and	other	practitioners	involved	in	a	patient’s	treatment	and	care.More	specifically,
  they	contain	clinical	facts	and	medical	reasoning	about	“the	care	delivered	to	patients	and	the	clinical	events	relevant	to	diagnosis	and	treatment.”[1]Progress	notes	are	professional	documents	that	communicate	important	information	on	a	patient’s	condition	between	multiple	providers.	In	mental	health	contexts,	they	must	be	stored	privately	and
  securely	in	a	HIPAA-compliant	manner.Progress	notes	are	professional	documents	that	communicate	important	information	on	a	patient’s	condition	between	multiple	providers.As	medical	and	mental	healthcare	providers	will	know,	progress	notes	play	a	vital	role	in	treatment	planning	and	service	delivery	across	a	wide	range	of	helping	professions,
  such	as	occupational,	physical,	and	speech	therapy.This	distinguishes	them	from	psychotherapy	notes,	which	contain	information	exclusively	related	to	a	patient’s	therapy	sessions.	Also,	unlike	progress	notes,	psychotherapy	notes	are	only	written	by	counselors,	therapists,	and	mental	health	practitioners	who	are	actively	involved	in	their	therapy.This
  table	outlines	a	few	more	differences	between	progress	and	psychotherapy	notes.Progress	NotesPsychotherapy	NotesPurposeCommunicate	patient	and	treatment	plan	information	between	providersDocument	insights	on	patient	and	therapyInform	treatment	plan	decisionsWritten	byAny	care	provider	involved	in	a	patient’s	treatment	plan,	e.g.,
  Social/Case	Workers,	GPs.Psychologist,	Psychiatrist,	Counselor,	PsychotherapistContentMay	include:Medical	historyAllergiesPrescriptionsPast	treatmentsCurrent	treatment	plan	informationCurrent	conditionDiagnosesTest	dataMay	include:Therapist’s	observations,	hypotheses,	feelings,	or	thoughts	about	the	sessionDo	not	include	information	or	data
  on	a	patient’s	medical	history,	treatment	plan,	or	diagnosesPrivacyMost	content	can	be	shared	between	a	patient’s	care	providersMost	content	can	be	shared	with	insurance	and	billing	partiesProtected	by	HIPAAPrivate	from	clientPrivate	from	other	care	providers	without	patient	permissionProtected	by	HIPAAFollowing	a	template	is	an	easy	way	to
  ensure	all	important	details	and	information	are	included	in	your	therapy	progress	notes.Many	treatment	software	solutions	offer	this	functionality,	with	a	variety	of	formats	and	outlines	for	different	healthcare	subsectors	–	psychiatry,	counseling,	and	more.For	instance,	Therapy	Notes	comes	with	Psychotherapy	Progress	Notes	templates	and	a	step-
  by-step	guide	to	help	psychologists	write	effective	progress	notes.	Each	step	corresponds	with	a	different	field	in	the	note,	starting	with	patient	information	and	ending	with	a	digital	clinician	signature:[2]Note	Header:	A	brief	overview	of	the	essential	practitioner,	patient,	and	session	information,	such	as	when	the	appointment	took	place,	its	duration,
  and	service	codes	for	practice	administration.Diagnosis:	ICD-10	or	DMS5	codes	might	be	relevant	here	if	the	patient	has	been	diagnosed	with	a	mental	health	condition.Patient	Presentation:	A	description	of	how	the	client	appears,	using	different	modalities,	e.g.,	cognitive	functioning,	affect,	or	behavior.Safety	Issues:	Any	important	information
  regarding	the	patient’s	well-being.Medications:	For	prescribing	clinicians	such	as	psychiatrists	and	general	MDs.Symptom	Description	and	Subjective	Report:	This	includes	reports	and	direct	quotes	regarding	the	patient’s	status.	These	may	come	from	the	client	themself	and/or	their	key	caregiver	and	might	relate	to	how	the	patient	is	feeling,	how
  they	view	their	progress,	or	their	opinions	on	the	mental	health	treatment	plan.Relevant	Content:	Objective	data	such	as	test	results,	documents,	and	therapy	notes	might	be	included	here	–	this	section	is	for	relevant	e-mental	health	information	that	could	‘complete	the	picture’	drawn	by	the	progress	note.Interventions	Used:	This	step	involves
  documenting	the	treatment	interventions	applied	and	the	broader	field	that	they	fall	into.	Examples	might	include	cognitive	restructuring	within	CBT	or	relaxation	techniques	as	part	of	a	mindfulness	training	program.Treatment	Plan	Progress:	Each	progress	note	should	mention	whether	a	client’s	treatment	plan	objectives	are	being	met.Signatures:
  Most	telecounseling	software	includes	the	ability	to	e-sign	documents	and	store	them	in	a	secure,	HIPAA-compliant	manner.If	the	step-by-step	guide	above	seems	familiar,	it’s	likely	because	this	particular	therapy	progress	notes	template	leverages	central	elements	of	the	SOAP	note	format.SOAP	Notes	follow	a	standard	4-point	layout	covering	critical
  information	on	a	patient’s	health	status.	A	specific	type	of	progress	note,	SOAP	notes	can	be	shared	with	any	other	therapists	and	care	professionals	the	client	may	be	working	with.The	four	sections	of	a	SOAP	method	note	are:Subjective	Data	on	a	patient’s	feelings,	experiences,	or	thoughts,	such	as	direct	quotes	or	their	observationsObjective	Data
  regarding	their	mental	or	general	health	status,	e.g.,	details	from	their	therapy	appointmentAssessment	Information	that	integrates	subjective	and	objective	details	with	a	therapist’s	professional	interpretation,	andPlan	details	regarding	any	adjustments	or	next	steps	that	the	counselor	and	client	feel	are	needed.Read	Writing	SOAP	Notes:	Step-by-
  Step	Guide,	Examples,	and	Templates	for	a	little	more	detail	on	what	each	section	should	feature,	as	well	as	a	host	of	helpful	formats	and	walkthroughs.Therapy	progress	notes	can	range	from	the	very	basic	to	more	comprehensive,	detailed	structures.SOAP	Notes	aren’t	the	only	format	used	in	mental	health	documentation.	Mental	health	progress
  notes	can	range	from	the	very	basic	to	more	comprehensive	structures,	like	the	10-step	example	Therapy	Notes	above.To	illustrate,	here	are	some	useful	free	templates	for	practitioners	to	use	and	download.Quenza	Therapy	Notes	TemplatesQuenza	offers	free	evaluation,	assessment,	and	intake	document	templates	for	e-counselors	in	its	Expansion
  Library,	including	a	range	of	forms	that	can	be	customized	to	use	as	therapy	progress	note	templates.	The	Outcome	Rating	Scale,	shown	below,	captures	data	on	a	client’s	individual,	interpersonal,	social,	and	overall	functioning	for	including	in	progress	notes.Therapy	progress	notes	often	include	information	on	different	areas	of	functioning	that	can
  change	as	a	result	of	therapeutic	intervention,	as	assessed	by	Quenza’s	Outcome	Rating	Scale.These	insights	can	help	practitioners	keep	track	of	how	a	client	is	progressing	with	therapy	and	can	be	used	to	populate	more	detailed	therapy	notes	that	include	the	session’s	focus,	client’s	name,	and	more.	With	professional	therapy	notes	software,	this	is
  often	as	simple	as	including	custom	fields	for	additional	information.SampleTemplatesSampleTemplates	also	provides	healthcare	progress	notes	formats	for	physical	therapists,	pediatricians,	general	clinicians,	and	therapists.These	include	BIRP	Note	templates,	SOAP	Note	structures,	integrated	progress	notes	and	billing	forms,	and	digital	samples	for
  electronic	note-taking.HarmResearch.orgHarmResearch.org	sells	Psychiatric	and	versatile	Visit	Progress	Note	templates	for	professional	use.	Their	psychiatric	progress	note	template	includes	fields	for:Patient	demographicsPresenting	problemPast	psychiatric	historyDiagnostic	interview	summariesPast	medical	history,	and	other	key	fields.When
  documenting	interventions	and	treatments	as	part	of	progress	note-taking,	appropriate	language	and	abbreviations	can	greatly	speed	up	the	process.Clinical	terminology	also	ensures	a	common	professional	language	exists	between	practitioners;	it	facilitates	better	understanding	and	establishes	a	consistent	frame	of	reference.In	therapy	for	mental
  health,	appropriate	terminology	can	be	a	combination	of	diagnostic	references,	such	as	DSM5	or	ICD-10	codes,	and	descriptive	terms	for	subjective	sections	progress	notes.Common	TerminologyThe	County	of	Santa	Clara	suggests	a	helpful	Counselor’s	Thesaurus	in	its	Clinician’s	Guide	Toolkit.	This	covers	commonly-used	descriptors	to	detail	different
  aspects	of	a	client’s	health,	appearance,	and	more.[3]The	Thesaurus	covers	categories	such	as:Affect,	Mood,	or	Disposition	–	e.g.	Lighthearted/carefree,	Depressed/Dejected/Dispirited/Disheartened,	Flat/Shallow/Dull/ListlessAttitude	–	such	as	Apathetic/Inert/Absence	of	Affect,	Belligerent/Quarrelsome/DisagreeableBehavior	–	ideas	include	Over-
  cautious/Too	Careful,	Lethargic/Sluggish,	or	Spontaneous/ImmediateWork	Habits,	Cognition,	Orientation,	and	more.InterventionsHaving	a	list	of	frequently-used	interventions	on	hand	for	quick	reference	can	be	particularly	useful	in	multi-provider	contexts,	helping	different	practitioners	understand	what	treatments	a	client	is	pursuing	with	other
  specialists.In	mental	health	disciplines,	these	interventions	might	address:[4]Anger	Management	for	healthier	self-expressionBehavior	Reinforcement,	commonly	part	of	intrinsic	coaching	methodologiesCollaborative	Problem-solving	for	relationship	counseling,	family	therapy,	conflict	resolution,	and	otherCognitive	Restructuring	–	a	thought-based
  CBT	interventionCommunication	Skills	Development	–	e.g.,	as	part	of	interpersonal	therapyCoping	Strategies	Development	for	addressing	a	diversity	of	mental	health	conditionsEye	Movement	Desensitization	and	Reprocessing	(EMDR)	for	trauma	counselingProgress/Objective	Review,	which	might	involve	collaborative	goal-setting	as	part	of	mental
  health	coachingIdentifying	Triggers,	as	seen	in	therapy	for	substance	abuse,	or	anger	managementImagery	–	e.g.,	within	a	graded	exposure	treatment	for	anxietyMindfulness	–	covering	Mindfulness-Based	Stress	Reduction	(MBSR),	Mindfulness-Based	Cognitive	Therapy	(MBCT),	and	formal/informal	Mindfulness	TrainingProblem-Solving	Skills
  Development	–	another	versatile	CBT	intervention,	andStress	Management	–	which	can	include	both	therapist-guided	activities	and	lower-intensity	Stepped	Care	interventions.Progress	notes	for	individual	and	group	therapy	will	differ	in	a	few	ways,	as	different	sections	may	be	required	for	distinct	criteria.	Their	overall	purpose,	however,	remains	the
  same.This	means	that	both	documentation	types	should	include	details	on	the	particular	patient	or	client’s	progress	overall,	important	identifiers,	and	relevant	notes	from	the	session	that	took	place.The	snapshot	below	shows	part	of	an	Individual	Progress	Note	created	using	the	ICANotes	software,	in	which	behavior,	content	of	therapy,	intervention,
  diagnoses,	and	treatment	plan	details	are	included:[5]Comparing	this	with	an	ICANotes	Group	Therapy	Progress	Note	Example,	we	can	see	the	latter	varies	only	slightly	with	regard	to	structure	and	content.Both	individual	and	group	therapy	notes	are	legal	documents	and	must	be	stored	securely.Another	clever	way	to	integrate	subjective	data	into
  therapy	progress	notes	is	by	inviting	clients	to	contribute	their	own	notes	from	sessions.One	example	template	in	Quenza’s	Expansion	Library,	Session	Notes	for	Clients,	offers	a	structured	form	for	patients	to	fill	out	with	insights,	reflections,	and	other	observations	from	a	therapy	appointment:Quenza’s	Expansion	Library	includes	free	example
  therapy	progress	note	templates	such	as	the	Session	Notes	for	Clients	form.By	collecting	a	patient’s	own	observations	online,	professionals	can	easily	copy	and	paste	direct	quotes	into	their	private	progress	notes.	All	data	is	securely	stored	on	the	one	HIPAA-compliant	therapy	platform,	and	visible	only	to	the	client	and	their	therapist.Whether	you’re
  looking	for	a	lightweight,	dedicated	Progress	Notes	software	or	a	bigger	solution,	these	apps	and	systems	all	come	with	templates	for	therapists	and	other	mental	health	specialists.SoftwareDetailsMyClientsPlus	is	a	versatile	mental	health	system	for	small	practices	and	solo	practitioners	–	it’s	also	relatively	simple	to	use	after	an	initial	learning	curve.
  With	MCP’s	Therapy	Progress	Notes	capabilities,	counselors	and	psychologists	can	choose	between	templates	for	psychiatry,	counseling,	general	psychology,	and	more.Within	different	sub-sectors,	you’ll	find	even	more	predesigned	formats	to	make	documentation	more	effective	and	efficient.	Examples	include	Therapy	Intake	Forms,	Treatment	Plans,
  and	Client	Information	Forms.MyClientsPlus	further	streamlines	Progress	Note	creation	with	diagnostic	codes	and	e-signatures	and	is	one	of	the	more	affordable	solutions	on	the	market.NameMyClientsPlusPrice$24.95+	monthlyGood	ForPsychologists,	e-Counselors,	Therapists,	Mental	Health	CoachesWebsite	mental	health	treatment	plans	and
  progress	notes	are	easy	to	create	with	Quenza’s	browser-based	software	and	apps.Templates	for	different	note	types,	such	as	SOAP	notes,	BIRP	notes,	and	more	can	be	built	quickly	using	drag-and-drop	tools,	and	the	software	stores	all	progress	notes	privately	and	securely	on	a	GDPR-	and	HIPAA-compliant	system.Forms	can	be	shared	through	a
  private	Portal	on	free	client	iPhone	and	Android	apps,	and	all	progress	and	results	are	shared	in	real-time	with	the	therapist.	Even	better,	Quenza	comes	with	a	huge	Expansion	Library	of	freely	customizable	note	templates.NameQuenzaPrice$1+	monthlyGood	ForPsychologists,	e-Counselors,	Physical	Therapy,	Speech	Therapy,	Occupational	Therapy,
  Mental	Health	Coaches,	Mental	Health	AppsWebsite	has	a	library	of	Progress	Note	templates	for	solo	practitioners	and	teams	and	comes	with	video	therapy	software	for	telehealth	sessions.Psychotherapy	Progress	Notes,	as	shown	above,	can	be	populated	using	clinical	codes	before	they	are	linked	with	a	client’s	appointments	for	easier	admin	and	use
  in	sessions.	When	a	Therapy	Session	starts,	the	software	automatically	creates	a	To-Do	list	item	reminding	users	to	create	the	relevant	documentation.NameTherapyNotesPrice$49+	monthlyGood	ForPsychologists,	e-Counselors,	Therapists,	Mental	Health	CoachesWebsite	basic	SOAP	frameworks	to	detailed	psychiatry	notes,	there’s	no	one	way	to
  write	a	great	progress	note.	The	way	you	choose	to	document	your	client’s	information	is	down	to	you	as	a	practitioner,	but	hopefully,	these	templates,	guides,	and	formats	will	be	of	value.If	you’re	happy	with	your	Therapy	Progress	Notes	software,	do	let	your	fellow	professionals	know	in	a	comment.	If	you’re	still	on	the	hunt	for	a	new	solution,	you’ll
  find	even	more	tips	and	advice	in	our	comprehensive	article	on	therapy	notes	software.We	hope	you’ve	found	some	clever	ways	to	streamline	your	therapy	documentation.	To	implement	what	you’ve	learned,	don’t	forget	to	explore	Quenza’s	Therapy	Progress	Notes	tools	with	your	$1,	30-day	trial.If	your	goal	is	to	have	a	bigger	positive	impact	on	your
  clients’	wellbeing,	Quenza	will	give	you	everything	you	need	to	create	professional,	accurate	notes	more	efficiently,	leaving	you	with	more	time	to	focus	on	the	mental	healthcare	solutions	that	matter.
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