Progress Notes in Mental Health

What Are Progress Notes?

Progress notes are a vital component of a patient's medical record. These notes document a patient's clinical status and treatment progress, whether during hospitalization or outpatient care. They serve several key functions:

• Tracking Patient Journey: Progress notes act as a historical record, allowing healthcare professionals to compare a patient's past and current health status.
• Communication Hub: Progress notes facilitate communication between physicians, nurses, and other healthcare team members. They provide a platform to share findings, opinions, and treatment plans.
• Informed Decision Making: Detailed progress notes enable healthcare professionals to make informed decisions about future care based on a patient's response to treatment.
• Transparency and Accountability: Progress notes ensure clear documentation of care and treatment. This transparency fosters accountability for medical decisions and actions.

Essential Qualities:

Effective progress notes should be:

• Readable and Concise: Easy for healthcare professionals to understand.
• Complete and Accurate: Capture all relevant information truthfully.
• Timely: Documented promptly after each patient encounter.

Combined Responsibility:

Physicians typically create at least one progress note per patient visit, while nurses document more frequently depending on the care level. These notes become part of the patient's medical record and are used for medical, legal, and billing purposes.

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Overall, therapy Progress Notes Should Address the Following Questions:

• What is the current medical necessity for services?
• What topics were discussed in the session?
• What clinical observations were made?
• What therapeutic interventions and techniques were employed and how effective were they?
• What progress or setbacks occurred?
• What signs and symptoms of the diagnosis are still present, marked up or down, or no longer present?
• How and by how much are treatment plan goals and objectives being met at this time?
• What are the client’s current limitations and strengths?

The Secret Ingredients

When dealing with a patient, therapists and other mental health professionals have various responsibilities. These include not only attentively listening to the patient and making sure he does not feel suffering alone, but also taking note of patterns and notable details such as how a patient chooses to articulate themselves, the patient’s presenting symptoms, diagnosis, medications, treatment plans, and prognosis. The table below summarizes progress notes, distinguishing features as per HIPAA requirements.

Progress Notes

Purposes

Progress notes document a client’s presentation, diagnosis, treatment plan, and progress towards achieving their therapeutic goals.

Written and used by

Written and accessible by all the patient’s healthcare providers, in addition to third parties and social workers.

Content

• The client’s presenting problems
• Medical history and diagnosis
• Prescriptions
• Treatment plan
• Symptoms progress
• Other relevant information

Style and Structure

• Concise
• Highly structured
• Formal, objective, and clinical language

Sharing and Privacy

Progress notes are HIPAA-protected and must be stored securely. They can typically be shared with:

• The patient’s other healthcare providers
• Third parties, like insurance companies,
• Patients themselves upon special request.

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How To Get It Done Perfectly!

As a therapist, knowing how to write effective progress notes is one of the most important aspects of your career. Well-written notes help you, as a clinician, evaluate the effectiveness of treatment and decide whether changes to the treatment plan are to be made. Add to it that such notes assist the therapist in keeping sessions on track. In simpler words, without notes, therapy sessions could easily escalate to irrelevant chit-chat discussions with no need to further explain.

It is unlikely that, over any length of time, a therapist can remember the specificities of previous therapy sessions’ interventions. By reviewing a client’s progress notes before a session, one can refresh their memories as to the client’s ongoing concerns, treatments employed, and progress towards treatment goals to date. This goes without mentioning that failing to employ best practices for therapy notes can have professional, legal, as well as ethical repercussions.

In short, know how to get your notes done quickly, efficiently, and up to the standards:

1. Be professional and to the point: The progress notes that you are writing today are likely to be read by other healthcare providers at any point your client decides to follow up with them. Opt out of using too many abbreviations that could confuse other providers later on. Writing effective progress notes ensures that anyone following up with the patient at any point in time can get a quick overview of the patient’s history and previous treatment plans.

2. Write objectively: Write in the third person, avoid slang, and do not express personal feelings about a client’s progress.

3. Back up your observations with unambiguous evidence: You should show the reasoning behind your observations. That is if you say a patient presents with a low mood, include clear markers of their affect, body language, or self-reported condition.

4. Make sure of the accuracy of crucial information, including date, time, place, and diagnostic code: These minor-seeming details are of the utmost importance when reviewing notes and inferring the patient’s progress with time.

5. Use a note template: Ready templates can make the note-taking process more organized and less time and energy-consuming while ensuring that you include all relevant information. You can tweak the templates once you are familiar with them to find a system that works for you. There are plenty of formats available to choose from: S.O.A.P., B.I.R.P., and D.A.P. Choose the one that you feel is the best fit for your needs.

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Progress Note Templates

The essential ingredients necessary for writing therapy progress notes are generally agreed upon. However, just like any list of ingredients, there are so many ways to combine them to serve different dishes. If we are to translate that into the world of progress notes, we can simply say that there is more than one right way to complete a progress note.

Interestingly, there are more flavors of progress notes than ice cream flavors you have ever tasted. However, the three most widely known note-taking templates are SOAP, DAP, and BIRP.

In Closing

Progress notes are crucial to benchmarking progress and ensuring that you and other providers communicate effectively about a client’s history, treatment plan, overall care, and other essential information. It is possible to be an excellent therapist but have poor documentation skills. And, vice versa, one can be quite adept at documentation but not be extremely helpful as a therapist. Of course, the goal is to be proficient in each of these realms! So, strive to achieve that, and if you need any help along the way, we are here for you!

Reviewed by: Brittainy Lindsey

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About the author

Salwa Zeineddine

Salwa Zeineddine is an expert in the mental health and medical field, being a medical student and having worked as a medical researcher at the American University of Beirut Medical Center for many years. She is highly knowledgeable about therapists’ needs and insurance requirements. Salwa has always considered herself a successful person, being the recipient of a full scholarship from the AUB Faculty of Medicine. Her achievements over the years made her realize that real success is one in which she can genuinely affect people’s lives, the reason why she became passionate about helping people better understand and manage their mental health. Salwa is an advocate for mental health, is committed to providing the best possible care for her patients, and works to ensure that everyone has access to the resources they need.

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