Writing Progress Notes

man-taking-notesI am in a new practicum placement and this is my first experience with writing a progress note after each session.  So far it takes me almost an hour to write each note, since I want to write down
everything that happened in the session.  How can I write notes in a shorter time and how do I decide what to leave out? 

This is a common dilemma for new trainees and it is important to develop facility with writing concise progress notes that include only the details that are appropriate for the client’s record.  At your stage of training, it is probably realistic to work toward writing a progress note in 15-20 minutes. Allowing time for this within 24 hours of your session is important in order to not fall behind and develop a backlog of incomplete or unwritten notes.

Let’s look first at the purpose of a progress note.  Progress notes are part of the client’s treatment record and may be viewed by the client and other third parties who are not clinicians.  Therefore, they should be relatively objective and descriptive without conjecture or emotionally charged judgments.  You should also avoid including details of the client’s current life and history that are emotionally sensitive and could bring psychological harm or shame to the client if they were revealed to a third party.  You do need to include enough detail about the client’s symptoms, therapeutic interventions and client’s progress to provide an accurate picture of the client and the treatment.

You will probably find it helpful to keep notes on the details of the client’s life and history, suggestions and guidance from supervision or consultation, a detailed description of the therapeutic interactions (sometimes called a process note), questions or hypotheses, and your emotional countertransference responses.  These are defined as psychotherapy notes which you keep for your own understanding rather than being part of the client’s record.  I recommend keeping psychotherapy notes in a separate file, using client initials or a random number in place of identifying information such as the client’s name or date of birth on these notes, and shredding these notes when you no longer need them.

Your agency probably has a specific format for the structure and content of a progress note.  In addition to the body of the note which describes the session, you need to provide information about the type of service you provided (individual or family therapy, group therapy, case management, home visit, collateral parent session); the date, time and length of the session; who attended; location of the session; and your hand or electronic signature including your degree and licensure status or title.  In some cases, your supervisor’s signature may be required as well.

The body of each progress note is a report on the status of the client’s symptoms and functioning and the progress in treatment.  It should include both the client’s report and your observations of her/his symptoms and current functioning, a description of your interventions and the client’s response, your assessment of areas of crisis or danger, the client’s general progress toward the treatment goals, and your plan for continued treatment or changes in the treatment plan.  It is helpful to include general information about the content or topics you talked about, with a phrase like “client discussed conflict with her partner about financial issues” or “client reported having contact with her mother which brought up painful feelings of rejection.”  A guide for the appropriate level of detail is that a progress note for a session lasting 45-60 minutes should generally be a half-page to a full page unless the client is in crisis or at risk, which requires documentation of your assessment and plan for safety and may extend into a second page.

I hope you are able to use these tips to write progress notes more easily and quickly.  Please email me with comments, questions or suggestions for future blog topics.