![]() ![]() This approach can also consist of incorporating a paper template form, containing sections for relevant information or checklists, that you can scan and attach to an electronic note. However, it is usually not possible to completely and thoroughly finish a progress note while also being attentive to your client, in addition to risking illegible handwriting.Ī hybrid approach might involve some handwritten notes to assist you in remembering some key details when you complete an electronic note later. Other therapists prefer to have a physical paper note, as they can complete some of it in-session. ![]() Nowadays most clinicians find it ideal to utilize an electronic health system (EHR) in order to automate and speed up the process with clickable checkboxes and fillable templates that hit all of the important elements required for documentation.Įlectronic notes also have the added benefit of being consistently legible, which is a major requirement of progress notes. There are many different ways you can write progress notes for therapy. These notes describe any notable symptoms or other relevant factors in the client’s presentation, changes since their last visit, their response to treatment recommendations, and interventions related to their goals, as well as assessment of client risk. They focus on the client’s condition coming in, as well as what transpired during the clinician’s interaction with the client.Ĭlinicians have a legal and ethical responsibility to document each treatment episode as part of the client’s official medical record. Mental health progress notes are a format clinicians use to document the details of every session. Download our free sample therapy progress note template! Download now
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