Client Progress Notes Examples for Therapists: Best Practices and Guidelines

Progress notes play an important role in providing effective mental health care. They record a client's path through therapy, capturing their challenges, growth, and treatment plan. Writing clear and concise progress notes is key to maintaining continuity of care and demonstrating the impact of therapeutic interventions.

Let’s take a look at the main parts of effective progress notes and offer practical examples to guide your documentation process. We'll also break down the main elements of a well-crafted note, discuss common formats, and share tips for efficiently documenting client progress over time. 

What is a Progress Note?
As the client moves through treatment, ongoing documentation in the form of progress notes becomes important. These notes, typically written after each session, capture the client's progress, challenges, and response to interventions. Progress notes should be concise yet informative, highlighting key themes, insights, and any significant changes in the client's presentation.

They ensure continuity of care, allowing other providers to quickly understand a client's history and current status, as well as provide legal protection if issues ever arise. Finding a balance between thoroughness and focus is key (we’ll get to guidance on this a bit later), knowing what to include and what to leave out. Importantly, progress notes should always connect back to the goals and objectives outlined in the treatment plan, demonstrating the client's trajectory and the effectiveness of the chosen interventions.

Basic Elements of Progress Notes
Progress notes should include several important elements to provide a comprehensive picture of the therapy session and the client's overall treatment journey. Here are the main parts to cover:

• Session Details: Start by documenting basic information such as the client name and date of birth, date of service, start and end time of the session, location (e.g., in-office, telehealth), and the provider's name and credentials. This information is important for billing purposes and helps establish a clear timeline of the client's care.
• Person-Centered Details: Include client-specific information that captures their unique experiences, thoughts, and feelings in that session. Use direct quotes when appropriate to authentically represent the client's perspective and maintain the integrity of their narrative. This approach helps to humanize the documentation and provides valuable insights into the client's personal experiences.
• Clinical Observations: Assess and document the client's mental state, including their appearance, behavior, mood, affect, and any notable changes since the previous session. This may involve conducting a mental status examination (MSE) to systematically evaluate various aspects of the client's presentation, such as their level of consciousness, speech patterns, thought content, and perceptual disturbances. Be specific and objective in your descriptions, avoiding vague or subjective language.
• Progress Toward Goals: Evaluate and document the client's progress, setbacks, or stagnation in relation to their established treatment goals. Note any improvements, challenges, or barriers to progress, and discuss how the session's interventions and insights relate to the client's overall treatment plan. This section helps show the effectiveness of the therapeutic approach and guides future treatment decisions.
• Risk Assessment: Identify any potential risks to the client's safety or well-being, such as suicidal thoughts, self-harm behaviors, or thoughts of harming others. Document the presence or absence of these risks, along with any specific plans or intent. If a risk is identified, outline the safety plan developed with the client, including any crisis intervention strategies, emergency contacts, or referrals to higher levels of care.
• Clinical Path Forward: Wrap up the progress note by outlining the next steps in the client's treatment, including any planned interventions, homework assignments, or changes to the treatment plan. This may involve discussing the reasons for introducing new therapeutic techniques, adjusting the frequency or duration of sessions, or coordinating care with other healthcare providers. Clearly documenting the clinical path forward helps ensure continuity of care and provides a roadmap for future sessions.

Progress Notes Examples and Templates
There isn’t one “correct” format for progress notes – therapists often use several popular templates to guide them in writing effective, compliant notes. When choosing a progress note template, consider the client's specific needs, the nature of the session, and the treatment modality being used. The chosen template should allow for clear, concise documentation that aligns with the client's treatment plan and goals. Let’s talk about three popular progress note templates, including an example for each.

SOAP Notes

The SOAP notes framework offers a structured approach to documenting sessions, focusing on four key areas: Subjective (client's reported experiences and perceptions), Objective (therapist's observations and findings), Assessment (analysis of the client's situation and progress), and Plan (next steps in treatment). SOAP notes offer comprehensive documentation, capturing both the client's perspective and the therapist's professional insights. Let’s look at an illustrative example:

S: Session conducted via telehealth. Client discussed ongoing conflicts with their partner, highlighting feelings of frustration and resentment. Client shared specific examples of miscommunication, stating, "We always end up arguing about chores that should just be simple."

O: Therapist utilized Gottman Method interventions, focusing on building the client's awareness of their emotional responses during conflicts. Therapist introduced the concept of gentle start-up to facilitate more constructive dialogue with their partner and practiced this through structured exercises in session. A brief role-playing exercise was conducted to reinforce positive communication patterns and repair techniques.

A: Client reports interpersonal stressors, characterized by frequent arguments, miscommunications, and feelings of frustration and resentment within their relationship. These difficulties in communication are significantly impacting relationship satisfaction and contributing to emotional distress. The client has reported increased anxiety and irritability related to these conflicts. No suicidal or homicidal ideation was suspected or disclosed. Client reported no progress towards goals to decrease arguing with spouse.

P: Client will implement the gentle start-up technique during discussions with their partner and will practice repairing interactions after conflicts. Therapist will facilitate additional role-playing in upcoming sessions to strengthen the client’s ability to manage and de-escalate conflicts. Progress will be assessed in the next session to evaluate improvements in relationship dynamics and emotional well-being.

DAP Notes
A streamlined version of SOAP notes, DAP notes concentrate on three main components: Data (objective information gathered during the session), Assessment (evaluation of the client's progress and challenges), and Plan (treatment goals and interventions). This simplified format is particularly useful for brief sessions or when focusing on specific behavioral targets. Let’s look at an illustrative example: 

D: Session conducted in person. Client expressed feelings of inadequacy, citing frequent instances of negative self-talk, such as “I never do anything right.” They shared specific situations at work where they felt inadequate, emphasizing how these thoughts negatively impact their work performance and emotional well-being. Therapist utilized gentle cognitive challenging techniques to address client’s negative self-talk, identifying patterns of cognitive distortions and introducing the concept of cognitive reframing. The therapist also observed that the client appeared visibly disheartened when discussing their perceived failures, yet showed openness to exploring reframing techniques.

A: The client’s low self-esteem appears to significantly affect their performance and overall well-being, contributing to feelings of inadequacy both professionally and personally. Symptoms of low self-worth, self-doubt, and persistent cognitive distortions were evident throughout the session. No suicidal or homicidal ideation was suspected or disclosed. Client's consistent cognitive distortions and negative self-perception indicate a need for focused cognitive restructuring interventions. The client did not make progress towards goal to increase meditation practice. 

P: Therapist will introduce cognitive restructuring exercises aimed at challenging the client’s persistent negative thoughts and cognitive distortions. Client and therapist agreed to schedule weekly check-ins to monitor client's progress and address any immediate challenges or changes in their thought patterns.

BIRP Notes
Designed for behavioral health settings, BIRP notes emphasize observable behaviors and responses to interventions. The four components include Behavior (client's actions and statements), Intervention (therapist's techniques and approaches), Response (client's reactions and progress), and Plan (future treatment steps). BIRP notes are particularly effective for tracking behavioral changes and evaluating treatment effectiveness. Let’s take a look at an illustrative example:

B: Client reported a recent relapse after six weeks of sobriety. They described feeling hopeless and unable to cope with stressors, turning to alcohol as a way to "numb the pain." Client stated they reached out to sponsor for support and plans to return to AA meeting after therapy session. Client appears sad, tearful when discussing their family’s reaction to relapse. 

I: Reviewed coping strategies that the client had used successfully during their sobriety period. Referred to relapse prevention techniques, including identifying triggers and creating a crisis plan. Therapist praised client’s action of reaching out to sponsor for support. Therapist expressed hope for client.

R: Client appeared remorseful but expressed a desire to regain control. They expressed  motivation to implement the relapse prevention strategies but voiced concern about facing future stress without resorting to alcohol. The client did not make progress towards treatment goal to maintain sobriety. 

P: Encourage the client to continue utilizing coping strategies, such as mindfulness and reaching out for support. Follow up with a review of relapse prevention techniques in the next session. Therapist will provide client with emailed copy of crisis plan, including numbers for hotlines if needed in the future. 

Documentation of Client Progress Over Time
Observing changes in a client's symptoms, functioning, and overall progress plays a vital role in effective therapy. Recording these changes helps you evaluate the impact of interventions, spot patterns, and make necessary adjustments to treatment plans through measurement-based care. Here are some key strategies for documenting client progress over time:

• Establish a baseline: During the initial sessions, collect information about the client's presenting concerns, symptoms, and functioning. This baseline data will serve as a reference point for tracking progress.some text
  • Example: "Initial assessment reveals severe anxiety symptoms (GAD-7 score: 18), significant sleep disturbances, and avoidance behaviors (e.g. procrastinating work tasks, arriving to work late nearly daily) impacting daily functioning."
• Use standardized assessments: Incorporate validated assessment tools, such as the PHQ-9 for depression or the PCL-5 for PTSD, to quantify changes in symptoms over time. Administer these assessments at regular intervals to track progress.some text
  • Example: "PHQ-9 scores show a decrease from 17 (moderately severe depression) at intake to 10 (moderate depression) after 6 weeks of CBT."
• Document behavioral observations: Note observable changes in the client's behavior, affect, and engagement during sessions. These observations provide valuable insights into their progress.some text
  • Example: "Client maintains eye contact, engages in spontaneous conversation, and displays a brighter affect compared to previous sessions."
• Highlight milestones and breakthroughs: Celebrate and document significant achievements, insights, or breakthroughs that occur during the therapeutic process. These milestones serve as evidence of progress and can boost the client's motivation.some text
  • Example: "Client reports successfully asserting boundaries with a difficult family member, a major goal they have been working towards in therapy."
• Monitor setbacks and challenges: Document any setbacks, relapses, or challenges the client experiences. Analyze these events to identify triggers, patterns, and areas needing additional support.some text
  • Example: "Client experienced a panic attack this week after a stressful work meeting. Explored coping strategies and identified the need for further skill-building in stress management."
• Regularly review progress: Allocate time during sessions to review progress notes with the client. Discuss their perceptions of growth, challenges, and goals for future sessions. Collaboratively adjust the treatment plan based on these discussions.some text
  • Example: "Reviewed progress over the past month, highlighting improvements in sleep quality and reduced avoidance behaviors. Client expresses satisfaction with progress but identifies ongoing struggles with self-esteem. Agreed to focus on self-compassion focused interventions in upcoming sessions."

Common Pitfalls to Avoid
Writing effective progress notes demands attention to detail and clarity. For more tips on writing therapy notes, here are some common pitfalls to avoid when documenting client progress:

• Vagueness in Descriptions: Using unclear or imprecise language can lead to confusion and misinterpretation. Rather than vague statements like "client seems better," provide specific examples of observable changes, such as "client reports a 50% reduction in panic attacks this week, and demonstrates improved eye contact and engagement during the session."
• Over-Documenting or Under-Documenting: Finding the right balance in the level of detail is important. Over-documenting can result in a cluttered, hard-to-follow narrative with too many unnecessary details while under-documenting may omit important information. Focus on including relevant, concise details that support the assessment and plan, without overwhelming the record with unnecessary information.
• Bias and Subjectivity: Progress notes should maintain an objective, non-judgmental tone. Avoid personal opinions, stereotypes, or stigmatizing language when describing client behaviors or progress. Stick to observable facts and evidence-based clinical impressions. For example, instead of "client is lazy and unmotivated," document "client reports difficulty initiating tasks and expresses feelings of low energy and motivation, consistent with symptoms of depression."
• Blaming or Labeling the Client: Refrain from using language that blames the client for their challenges or assigns negative labels. Instead of "client is resistant to treatment," consider reframing it as "client expresses ambivalence about change and may benefit from further exploration of motivational factors."
• Neglecting Cultural Factors: Be mindful of cultural, social, and contextual factors that may influence the client's experiences and progress. Avoid making assumptions based on race, ethnicity, or other cultural identities. When relevant, document the client's cultural background, experiences of discrimination, and any cultural considerations in treatment planning.
• Inconsistency or Contradictions: Ensure that progress notes are consistent across sessions and avoid contradicting previous documentation. Regularly review past notes to maintain continuity and address any discrepancies or changes in the client's presentation or treatment plan.

Being aware of these common pitfalls while aiming for clarity, objectivity, and cultural sensitivity will help create progress notes that accurately reflect the client's journey and support effective treatment planning.

Key Takeaways
Writing effective progress notes is an important skill for mental health professionals. Documenting client progress, challenges, and treatment plans consistently and objectively helps therapists improve the quality of care they provide. Key points for crafting excellent progress notes include:

• Maintain a clear structure: Use formats like SOAP, DAP, or BIRP to organize information and ensure all relevant aspects of the session are captured.
• Be specific and objective: Record observable behaviors, use direct clients quotes to reflect the client’s perspective accurately, and avoid vague or judgmental language.
• Link interventions to treatment goals: Clearly connect the therapist's actions and the client's responses to the overall treatment plan.
• Monitor progress over time: Regularly review past notes, celebrate milestones, and adjust the treatment plan as needed based on the client's progress.
• Prioritize ethical and legal considerations: Protect client privacy, maintain accurate records, and adhere to mandatory reporting requirements.

Continuous learning and professional development are important for refining clinical documentation skills. Therapists should regularly review their progress notes, seek feedback from peers or supervisors, and participate in documentation-focused training or workshops. Engaging in ongoing education helps therapists stay current with best practices, regulatory changes, and technological advancements in the field.

Progress notes play a significant role in supporting therapeutic outcomes and ensuring accountability. Dedicating time and effort to crafting high-quality notes demonstrates therapists' commitment to providing exceptional care and facilitating their clients' growth and healing. Skillful note-writing benefits individual clients and contributes to the overall integrity and effectiveness of the mental health profession.

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