Progress notes. A fine way to document and keep track of your session with your clients and show them the progress you've made toward setting your treatment goals.
Cool, right? But it isn’t always the case. A study shows that therapists and doctors spend an average of 135 hours per week on clinic documents. That just shows how tedious it is to write progress notes. People say progress notes are easy, but writing them in a compliant (though not always the case) way is the difficult part.
From my experience over the years, when starting out, it is always advised to try and remember the exact things that happened while the details were getting hazy.
But at the end of the day, good progress notes are not all about compliance. They’re your guide for the treatment and legal protection and can even make you a better therapist and doctor. As new innovations and AI tools emerge, the process can be done way faster and simpler.
So whether you're an experienced therapist or a newbie who just graduated and is still confused about what to do, this guide on how to write progress notes will teach you all the aspects you need to know with different examples, formats, and templates using the AI tools.
Let us begin.
How to write therapy progress notes with AI
Let me tell you something: AI has completely transformed the documentation game. I used to spend my lunch breaks furiously making notes, trying to remember whether Sarah (client) said her anxiety was a 7 or an 8 out of 10. Now? My notes almost write themselves.
The main objective is to strike the correct mix between “technology and expert judgment.” AI can handle the heavy lifting of transcription and basic formatting, but you, as the clinical expert, must still offer insight and ensure accuracy.
I've been experimenting with various AI tools for almost two years, and while they aren't perfect, they've reduced my documentation time by half. What's the biggest game changer? Voice recording devices that can transcribe and analyze conversations in real time.
However, you cannot simply set it and just forget it (DO NOT DO THIS). These tools are meant to be used as assistants and not to do the entire work. I learned the hard way when I trusted an AI-generated letter without thoroughly reviewing it and almost missed a critical detail about a client's medication adjustment.
What are therapy progress notes?
Progress notes are essentially a professional diary of what occurred during a treatment session. They record the client's presentation, the interventions you utilized, how they responded, and your plans for the following session.
Consider them to be breadcrumbs along the therapy route. These notes are your lifeline if something legal happens, if you need to transfer care, or if you want to know if your interventions are effective.
I recall back in the day my supervisor telling me, "If it was not documented, it didn't happen." That terrified me at first, but it is actually true in a legal sense. Your progress reports may be subpoenaed, reviewed by insurance companies, and used to demonstrate the medical necessity of the therapy.
Finding the right balance between too much and too little detail is a difficult endeavor. You want to ensure that you have enough material to develop an accurate picture, but you don't have to write a novel about each session. The most successful notes are succinct, objective, and centered on therapeutically important information.
How to automate therapy progress notes writing with AI
Okay, this is where things get really interesting. The automation processes used involve several steps, and I've refined this system through lots of trial and error.
The whole process starts with capturing the session properly. You can't just throw a phone on the table and hope for the best; trust me, I tried that once and ended up with a recording that sounded like it was made underwater.
Step 1: Capture the session with PLAUD NOTE or PLAUD NotePin
Consent is absolutely critical here. You need informed consent before recording anything. You need to have a specific consent form just for session recordings, and make sure to go over it thoroughly with every client.
The conversation will usually go something like this: "I use an AI tool to help with my note-taking, which involves recording our sessions. This helps me focus more on you during our time together instead of frantically scribbling notes. The recording is encrypted, automatically deleted after processing, and never shared with anyone."
For the actual recording, personally, I've been using the PLAUD NotePin, which is this tiny device that clips onto your shirt. It's way less stressful than having a phone or tablet sitting on the table between you and your client.
One thing I learned is that position matters. Make sure not to clip it too low on your shirt, or it will pick up every stomach rumble and chair creak. Now, try to position it higher, closer to your collar, and the audio will be much cleaner.
Step 2: Access the recording
Once the session ends, the magic happens pretty quickly. The PLAUD app syncs automatically, and within a few minutes, you have a full transcription waiting for you.
Know that AI transcription isn't perfect; it sometimes struggles with clinical terminology or proper names. But it's gotten way better over the past year. I'd say it's not too shady.
The preliminary analysis feature is quite cool. The program detects important themes, emotional patterns, and even prospective risk factors. It's like having a research assistant who listened to your session and underlined the most significant points.
Usually, I review the transcription while it's fresh in my memory, making quick corrections for any major errors. This whole step takes maybe 5-10 minutes max (not always typical if you are just starting out).
Step 3: Choose and customize a template
This is where PLAUD really shines with its photo-to-template feature. I had this paper SOAP note template that I'd been using for years, and I was able to just snap a photo of it. The AI converted it into a digital template that matches my exact format.
Option 1 - Custom templates:
The photo-to-template feature blew my mind the first time I used it. I literally took a picture of a crumpled form from my desk drawer.
And within minutes, I had a perfectly formatted digital template. You can tweak the fields, adjust the layout, and save it as your go-to format.
If you're someone who's particular about your documentation format (and let's be honest, most of us are), this feature is a game-changer. You don't have to adapt to some generic template. The AI adapts to your preferred style.
Option 2 - Select a pre-template:
If you're not attached to a specific format, the app offers several standard templates. They have SOAP notes, DAP notes, BIRP notes, and even some specialized formats for different therapy modalities.
I've tried most of their pre-built templates, and they're solid. They include all the essential fields and follow best practices for documentation. For newer therapists who are still figuring out their documentation style, these are perfect starting points.
Step 4: Generate and review the draft
Here comes the phase where the AI does the heavy lifting. It takes your transcription, runs it through the template, and generates a draft progress note. The first time this happened, I literally exclaimed "holy shit" in my office.
The AI is pretty good at gathering relevant facts. It can recognize when a client mentions specific symptoms, measure mood ratings, and even detect linguistic trends. However, it is important to note that this is only the beginning.
Manual review is absolutely essential. Make sure to spend about 10-15 minutes going through each AI-generated note over and over. Make sure to check for accuracy, add clinical impressions, and make sure the language meets professional standards.
Sometimes the AI misses nuance or context. Like, “it might note that a client laughed during the session without capturing that it was nervous laughter when discussing trauma.” That's where your expertise and clinical judgment come in.
Step 5: Finalize and archive
After you’re satisfied with the note, make sure to finalize it in the app and then transfer it to my main EHR system. This is where HIPAA compliance becomes really important; you need secure transfer and storage protocols.
Keep the finished notes in your secured EHR system, and configure the app to destroy the original recordings after 30 days. Some colleagues preserve them for extended periods of time for quality assurance, but I normally try to restrict data retention to a minimum for privacy reasons.
The entire procedure, from session finish to filed note, currently takes me around 20-30 minutes. When compared to the hour or more I used to spend per note, it's clear why I'll never go back to manual documenting.
What should be included in therapy progress notes?
This is where many new therapists become stuck. What amount is too much? What is considered too little? How can you convey the core of a 50-minute session in a brief note?
They need to capture the client's current functioning, what happened during the session, your assessment of their progress, and your plan moving forward.
I always make sure to include the client's mood and situation when they arrived versus when they left. This gives me a quick snapshot of the session's impact. If someone comes in agitated and leaves calm, that's clinically significant information.
Remember: Safety should always be documented. Even if there are no concerns. Make sure to make a brief note about the suicide risk assessment. It takes two seconds to write "No SI/HI reported," but it could save your license if questions arise later.
Interventions used during the session are crucial. Don't just say "provided therapy"; be specific. "Used cognitive restructuring techniques to address catastrophic thinking patterns" tells a much clearer story about what actually happened.
Any small step toward treatment goals needs to be addressed regularly. Always try to reference specific goals in at least every third note, tracking measurable changes when possible.
What are some of the different mental health progress note types?
The mental health sector has various standardized note forms, each with its own set of advantages and disadvantages. I've used all of them at various stages of my career, and the choice mostly relies on your work environment and personal preferences.
Most agencies or practices will define their preferred format, but it is important to recognize the variances. Certain forms are more suited for specific sorts of treatment or client presentations.
The key is consistency; whatever format you choose to adopt, stick to it. Insurance firms and regulatory authorities like consistent documentation patterns; never forget that.
SOAP Notes + Sample
SOAP notes are arguably the most popular format in healthcare settings. The acronym (Subjective, Objective, Assessment, and Plan) provides a logical flow for arranging session material.
Subjective refers to what the customer says: their problems, symptoms, and subjective experiences. This is where you record their precise words when applicable. I frequently utilize quotations for exceptionally important points.
The objective comprises your observations of the client's presentation, conduct, and mental state. This should be factual and observable, not interpretative. "Client appeared tearful" rather than "Client was sad."
Assessment is your clinical opinion of what is going on. This is where your expertise shines: you analyze subjective and objective data to develop clinical impressions.
The plan outlines what you're going to do next. This includes homework assignments, medication referrals, changes to the treatment approach, and goals for the next session.
Sample SOAP Note:
S: The client admits feeling "overwhelmed and anxious" about the next job interview. State’s sleep has been bad (4-5 hours every night) for the past week. "I keep thinking about all the ways I could mess up."
O: The client appeared restless and fidgeted with his hands throughout the session. Speech is slightly pressured. Made good eye contact. The mood appeared worried, and the emotion was congruent. No psychotic symptoms were noted.
A: The client is presenting with anticipatory worry about a job interview. Sleep disturbance and catastrophic thought habits are some of the symptoms. Responds to cognitive behavioral therapies during the session.
P: Continue CBT with a focus on cognitive restructuring. Homework assignment for thinking records. Schedule a follow-up session the day following the interview to process the experience. No medicine referral is required at this time.
DAP Notes + Sample
DAP notes are becoming more well-known, particularly in community mental health settings. They stand for Data, Assessment, and Plan, which is essentially SOAP without the distinction between subjective and objective data.
I prefer DAP notes since they are more streamlined. You are not attempting to artificially segregate what the client says from what you observe; it is all simply data to be studied.
The Data section contains all important information from the session, including client reports, observations, interventions utilized, and client reactions. It is thorough yet succinct.
Assessment is the clinical interpretation of data. What trends do you see? How is the customer progressing toward his or her goals? What is your diagnostic impression?
The plan covers the next steps, just like in SOAP notes. This should be specific and actionable.
Sample DAP Note:
D: The client arrived ten minutes late, apologizing for traffic. Reported mood as 6/10 (up from 4/10 last week). Completed the homework assignment (daily mood monitoring). Work stress and family problems have been identified as potential factors for depressive episodes. During the lesson, we practiced grounding skills while discussing family difficulties. demonstrated a solid comprehension of the coping skills provided.
A: The client is gradually improving his mood control and understanding of triggers. Actively participating in treatment and completing homework assignments. Depression symptoms appear to be stabilizing with current treatments.
P: Continue weekly sessions that focus on stress management and family boundary setting. Assign progressive muscular relaxing exercises. If the pattern persists, consider a referral to family therapy. Next appointment is set for [date].
BIRP Notes + Sample
BIRP notes are ideal for situations that require intervention tracking. The acronym represents Behavior, Intervention, Response, and Plan.
Behavior describes your observations regarding the client's presentation and stated symptoms. This is similar to the objective part of SOAP notes.
Intervention describes the therapeutic techniques or approaches you utilized during the session. This part is quite explicit regarding your clinical actions.
The response describes how the client responded to your interventions. Did they engage? Were they resistant? Did you notice an improvement?
The plan includes the next actions and future initiatives.
Sample BIRP Note:
B: The client appeared with a bland demeanor and little eye contact. Reported feeling "numb" and having trouble concentrating at work. Sleep patterns are high (12+ hours on weekends and 4-5 hours on weeknights).
I: Use motivational interviewing techniques to investigate the client's ambivalence about medication compliance. Psychoeducation was provided on depression and sleep hygiene. Introduced behavioral activation concepts and assisted the client in identifying a pleasant activity for the week.
R: The client was originally averse to discussing medicine but became more open after considering the advantages and cons. Showed interest in the behavioral activation technique. We agreed to organize one pleasurable activity before the following session. The effect improved slightly toward the end of the session.
P: Continue motivating interviews about medication adherence. Increase behavioral activation activities. Coordinate with the psychiatrist about medication problems. Set up weekly sessions for now.
Are progress notes the same thing as psychotherapy notes?
This is one of those questions that trips up a lot of therapists, and honestly, the distinction is super important for HIPAA compliance.
Progress notes and psychotherapy notes are definitely not the same thing, even though people often use the terms interchangeably. The difference matters big time when it comes to privacy protections and who can access your documentation.
Progress notes are part of the designated record set. They document treatment progress, interventions used, and clinical status. These can be requested by insurance companies, other healthcare providers, and even patients themselves.
Psychotherapy notes, on the other hand, are your personal observations and analysis that go beyond what's necessary for treatment documentation. These have special privacy protections under HIPAA.
I keep my psychotherapy notes completely separate from my progress notes. The psychotherapy notes might include my hunches about family dynamics, countertransference reactions, or sensitive details that aren't clinically necessary to document.
The key test I use: if someone else needed to take over this client's care, what would they need to know? That goes in the progress note. Everything else—my personal reflections, therapy process notes, and supervisory discussions—always goes in the psychotherapy notes.
Most AI tools are designed for progress notes, not psychotherapy notes. I wouldn't feel comfortable having an AI analyze my personal clinical reflections or countertransference reactions.
Conclusion
Writing good progress notes does not have to be a challenge in your clinical profession. With the appropriate approach—whether it be traditional documentation ways or newer AI-assisted tools—you may generate comprehensive, suitable notes without sacrificing hours of your personal time.
The most significant factors are consistency, accuracy, and clinical relevance. Your notes should clearly reflect the client's route and the therapeutic work you did together. They should protect you and your client while also fostering excellent service.
Whether you are just starting out or wish to improve your present process, make an effort to develop excellent documentation habits. Your future self (and clients) will appreciate it. Consider sharing your own documentation strategies or concerns with others; we can all benefit from each other's experiences!
FAQ
How do you write a simple progress note?
Begin with the fundamental session details: date, duration, and client presentation. Document what was addressed, the interventions employed, and how the client responded. Finish with your plan for the next steps. Keep it short yet detailed, emphasizing clinical relevance over superfluous information.
What is an example of a progress note?
"The client reported a better mood (7/10 vs. 5/10 last week) and completed the anxiety tracking homework." We discussed CBT-based coping strategies for occupational stress. The client did deep breathing exercises and reported feeling more in control. ' Plan: Continue the CBT technique, assign gradual muscle relaxation, and schedule a pharmaceutical appointment with the psychiatrist.
How do you write a progress report note?
A progress report note follows a standardized format that begins with client identification and session data, then documents present symptoms and functioning, describes interventions utilized, notes client reactions, and concludes with next steps. Use objective language, incorporate quality facts where possible, and maintain HIPAA compliance throughout the process.
