Documentation is crucial in providing excellent patient care. It allows the healthcare provider to assess, plan, and track the patient’s journey and make any necessary adjustments in a timely manner. At the same time, progress notes enable the patient to make educated decisions about their health and treatment plan.
The challenge with writing progress notes is that they require quite a lot of time and effort, especially if the mental health professional doesn’t have a method in place that would allow them to streamline the process.
There’s also not a lot of consensus regarding what therapy progress notes should contain. Some are overzealous and write down every piece of information while others prefer sticking to the essentials.
While this approach is neither fundamentally good nor bad, the purpose of this article is to help mental health therapists find the approach that works best for them and create a progress note format that would allow them to streamline their work.
A Short Definition
As the name suggests, therapy progress notes are details, remarks, and observations that healthcare professionals write down to keep track of a patient’s progress during therapy.
Don’t confuse progress notes with psychotherapy notes. While the first contains details about the treatment plan, medical history, and other important information, psychotherapy notes focus on the therapist’s diagnosis, observations, and thoughts regarding the patient.
Most importantly, psychotherapy notes are private – the patient doesn’t have the right to access them and the therapist may not share them with other health providers without the patient’s permission. Therapists can, however, disclose the notes to protect themselves in court, for example, or if the patient is a danger to themselves or to others.
As opposed to psychotherapy notes, patient progress notes are meant to be shared among the professionals that are supervising the patient. Without updated information regarding the patient’s treatment, medical and billing records, and other essential details, they would have to start from square one during every session.
Because various mental health professionals share them, progress notes should have a consistent style, be written clearly, and be easy to access. A progress note template could be of great help in ensuring that everyone sticks to the same format and maintains unity in style and design.
As a rule of thumb, use the SOAP method of documentation to track patients’ progress in a structured and organized way:
- S (Subjective:) Present the symptoms and current conditions as described by the patient. Include the chief complaint too. If the patient says that he’s been feeling rather stressed lately and has trouble sleeping, write that down.
- O (Objective:) Write down any observations you made during the physical examination.
- A (Assessment:) The notes should always include a summary of the patient’s diagnosis.
- P (Plan:) Make a list of all the methods and tools you plan on using to treat the patient. This might include lab tests, interviews, the medication taken, and so on.
Some Things to Keep in Mind When Writing Progress Notes
Most therapists share the same philosophy in writing mental health progress notes: they should be clear, to the point, and help other professionals make a quick assessment of the patient’s current condition. The way they write them, though, might differ with some insisting on the details of each session while others focusing only on essential information.
So, what should you do to ensure that the notes are effective and easy to understand?
Here are a few things to consider when writing progress notes:
1. Make Sure Your Notes Are Compliant
The first thing to keep in mind when creating progress notes is their requirements. Ensure your therapy progress notes comply with state and federal laws, follow the treatment plan requirements, are in line with contract requirements, and enable easy collaboration between professionals.
You need to consider many factors for your progress notes to be safe, legal, and compliant. Check the following:
- Your state’s record-keeping laws;
- American Psychological Association’s (APA) Record Keeping Guidelines (you can access them here);
- The insurance company’s criteria;
- The policy of the institution you are working for;
- The requirements of any third-party contract.
2. Consult with the Patient
Talk with your patients about the progress notes and ask them if they have any specific requests. Some patients may not want you to go into too much detail about their issues or current situation, while others don’t care much about the documented information.
Writing progress notes is a balancing act, and you need to find the right line between responding to your patient’s wishes and making sure that you’ll be protected in case of a legal suit.
If your client is not comfortable with information about them being shared with other health providers and third parties, then you could use psychotherapy notes instead of progress ones. That way, you can document each session and keep track of their progress separate from their medical records.
3. Try to Be as Specific as Possible
Regardless of how much information you plan on including in your therapy progress notes, make sure that it is specific. Stay away from vague terms that could leave room for interpretation. Write what you observe as accurately as possible.
For example, instead of saying that the patient is feeling ‘burned out,’ you could consider specific symptoms, such as “unable to cope with simple tasks, ” “cynicism and detachment,” and so on.
Likewise, if you want to include a certain medication in the patient’s treatment plan, provide the motivations behind your decision. Other clinicians may not grant your request just because you made a suggestion in a document. Try to justify your decision by listing the patient’s symptoms or writing about how they describe their feelings and experiences.
Can You Create Progress Notes for Group Therapy?
Group therapy is an excellent way for patients to gain insights from people who are struggling with the same problems as they are, all under the supervision of a therapist.
Writing progress notes for group therapy differs from one-on-one sessions, as the clinician can no longer focus on individual problems and has to look at the bigger picture.
So, what should they do to ensure that the therapy progress notes are accurate, relevant, and helpful?
Here are a few ideas:
- Start by writing down the basic information: the name of the group, the number of clients, the time and date of the session and any particularities.
- Mention the methods and treatment plan used during the session.
- If you are going to make notes about an individual participant, do it while keeping their goals in mind. Include objective assessments about their look, body language, facial grimaces, and so on. Write down the statements that point to their struggles.
- If the group interacts with different mental health professionals, then you need to ensure that your colleagues will be able to assess correctly the problems and objectives of the group by simply glancing at the notes. That way they can pick up from where the other therapist left. Otherwise, precious time would be wasted figuring out what they need to do. Using a sample progress note for mental health therapy will simplify this process. You can find plenty of group therapy progress notes examples online. Just choose one that is clear, easy to fill out, and user-friendly.
11 Elements That Progress Notes Should Contain
While the style and format of progress notes might differ depending on the software you are using, they should contain the following information:
- The Note Header
The top of the document should contain basic information about the therapist, patient, date and time, duration of the session, service code, and patient insurance.
- The Diagnosis
A standardized progress note format will automatically show the diagnosis code based on the information provided about the treatment plan or the most recent notes.
- Information about the Patient
Good progress notes contain information about the patient’s current state to help fellow clinicians make educated observations about their progress. Include details about their mood, affect, functional status, etc.
- List of Medications
List any medications the patient is currently taking. It will be easier for the entire team to determine whether the treatment plan is effective, or if they should consider adjusting it.
- Document the Patient’s Experience
Write down any relevant information regarding the client’s experience, symptoms, and mood since the last visit. Include verbatim about how they feel about the treatment plan.
For example, mention if they say something like “I think that the coping strategies you taught me last week really helped me deal with my anxiety” or “I don’t feel like the solutions you mentioned previously did anything to improve my sleep problems.”
- Include Any Safety Concerns
Include any safety concerns, even if we are only talking about mere allusion. If you think that the patient might be a danger to themselves or to others, mention that in the progress notes and provide clear examples to justify your hypothesis.
- The Methods Used During the Session
List the interventions used during the current session, such as exploration of emotions, mindfulness training, role-playing, symptom management, and so on.
- Document the Progress
Document the progress toward your treatment plan objectives to determine its effectiveness and whether you need to make any adjustments.
- Any Relevant Information
This might include any behavior that you observe, and that is relevant to the betterment of the patient. One common mistake therapists make when writing progress notes is that they focus on the behavior they are targeting and completely ignore the behavior that they are observing. The latter can tell a lot about a patient’s progress and help you establish the right method of intervention.
- Any Recommendations
Conclude the plan with a prognosis and recommendations for the improvement of the treatment plan. For example, if you consider that the patient should change his medication, mention that, but provide solid arguments to back up your suggestions.
- Don’t Forget to Sign It
Even if you are using an app, most medical progress note software will contain your digital signature. You will probably have to select something like “Sign this form” to save it after you’ve completed the progress note.
Progress Notes Software to Consider
Documentation is the soul of data-based healthcare solutions. Carefully documenting the effectiveness of the treatment plan can make a significant difference in patient progress. But, as any clinician will tell you, that is easier said than done. Especially when it comes to multidisciplinary therapists that oversee multiple patients, keeping track of everyone’s plan and progress can be a challenge.
Luckily, clinical documentation in the digital age can be simplified, streamlined, and made more effective with the help of progress notes software.
Here are progress notes software that might make your life easier:
This app allows clinicians to use different progress notes formats based on their treatment goals and objectives. It generates automatic notifications to alert therapists when documents are missing or the information is incorrect.
With a simple and user-friendly interface, the Valant is defined to provide a clutter-free space for progress notes taking. Clinicians must enter data in a structured way, making the document easier to read.
One thing that makes this software a great option is the fact that the sections are collapsible, making it easier for clinicians to access important patient information such as medical history, diagnosis, list of medications, and so on.
Documentation is essential for crafting and implementing the right treatment plan. Without it, clinicians would act in a void, not knowing if their previous efforts had any effects. Taking progress notes can be daunting, but with the right approach and a well-defined software, documentation production can become easier than ever before.
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