Progress Note Template for Therapists
What is a psychotherapy progress note?
A progress note is a part of a client’s medical record that serves as a documentary summary of a client’s clinical status and progress in an outpatient therapy session. Most mental health therapists use a progress note template to help write their psychotherapy progress notes.
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Because the clinician completes a progress note for every therapeutic session, it is likely to be the most numerous of the various medical notes that make up a medical record.
For this reason, the progress note can be considered the “backbone” of the client’s medical record.
Therapy Progress Note Template (PDF)
Therefore, having a comprehensive and efficient progress note template should be a priority for all mental health professionals with direct client contact, whatever their background or specialty.
But what do you include in, and how do you structure, a mental health progress note?
How do you write a progress note?
Let’s go through each of the components of a progress note and look at some examples.
Components of a progress note
There is no industry-standard progress-note template, which can create confusion around both the specific information to include in the note, as well as how to organize the information in a meaningful way.
There are, however, generally agreed upon components that will be present in most progress note templates, though the names of these components may vary from one template to the next. Generally speaking, these components include client and session information, diagnosis, topics/issues discussed in session, clinical notes, therapeutic intervention(s), assessment, and plans.
Client and session information
A progress note will most often begin with essential information about the session including the client name and date of birth; session date, time, and duration; service code; and finally session type and participants.
Example
Client: John Doe
Client Date of Birth: 01/01/1999
Session Date: 01/01/2022, Time: 12:00PM, Duration: 45 mins
Service Code: 90834
Session Type: Online
Participants: Client only
Diagnosis
The diagnosis component consists of the ICD-10 diagnosis code and a description of the client’s primary diagnosis.
Example
Diagnosis Code: F41.1
Diagnosis Description: Generalized Anxiety Disorder
Topics/Issues discussed
The topics component consists of a list of the topic headings of the therapeutic content of the session. This section is often very brief.
Example
Topics Discussed: Client’s recent experience with generalized anxiety as he prepared for an upcoming work assignment.
Download my Progress Note Template
Click here to download our progress notes template
Click here to download our notes bundle (includes progress notes template)
Interventions
The interventions component consists of the specific therapeutic interventions of the clinician. This section too is often very brief and may be found in list form on many templates.
Example
Intervention(s): CBT/Behavioral modification, increasing coping skills
Clinical notes
The clinical notes component consists of any additional clinical information the therapist may want to include in the progress note, such as therapeutic rationale for any topics discussed or interventions; a description of client symptomology, including significant changes in frequency, intensity, and duration; subjective report of the client’s functioning or progress in treatment; or any objective content including clinically significant observable behavior. Using a Therapeutic Interventions List can be a helpful reference while writing your notes.
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Example
Notes: Client was active and engaged throughout the session. Therapist supported client with identifying and challenging a catastrophizing belief about an upcoming work assignment and then supported the client with identifying an alternative belief when client determined that the original belief was not supported by evidence. The client reported no significant change to symptomology since the last session.
Assessment
The assessment component consists of the clinician’s assessment of the client’s mood, affect, mental and functional status, and risk assessment.
Example
Assessment: Client’s mood was anxious and affect normal throughout the session. Mental status was normal/intact, and no risk of harm to self or others was evident by therapist’s assessment or self-report.
Plan
The plan component consists of any therapeutic plan the intermediary between the current session and the next one, care coordination between the therapist and other providers, or plans for future areas of therapeutic exploration in session.
Example
Plan: Therapist and client will meet again at the same time next week, on 01/08/2022 at 12PM. Therapist has provided a thought-challenging exercise to the client to use as needed throughout the week to challenge anxious thoughts.
Conclusion
The substance of the above-listed components will be included in most comprehensive progress notes, though it may be combined into different heading titles depending on the template used. The bottom line is that different progress note templates each have their distinct characteristics, but will ultimately share a significant amount of common ground as they converge on core tenets of documentary coverage.
Note: Different organizations — as well as insurance providers — may have different requirements as to what should and shouldn’t be included in a progress note. Therefore, it’s always advisable to check with whichever agencies you are affiliated with to ensure you are meeting their documentary standards.
