Blog > Documentation > How to Write Progress Notes: Tips, Templates & Examples
How to Write Progress Notes That Are Clear, Compliant, and Clinically Useful
Progress notes are a vital part of every behavioral health clinician’s workflow. They document what occurred in a session, demonstrate medical necessity, and support both continuity of care and reimbursement. But writing progress notes can also be time-consuming, especially if you’re not using the right tools or approach. This guide breaks down everything mental health professionals need to know about how to write progress notes effectively. You’ll learn what to include, see examples of strong clinical documentation, get a progress notes template you can use immediately, and explore how progress note software can simplify your workflow.
Last Updated: August 28, 2025
What You'll Learn
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What to include in a high-quality progress note, from presenting concerns to treatment planning
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How to write clear, compliant, and clinically useful documentation using objective language
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A complete sample progress note and suggested template to streamline your workflow
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How progress note software like ICANotes can save time and improve documentation quality
Contents
Understanding Progress Notes
Progress notes are formal clinical documents written after each session to record the patient's status, symptoms, interventions, and progress toward treatment goals. These notes are part of the patient's medical record and must meet ethical, clinical, and legal standards.
Unlike casual observations or reminders, progress notes must be:
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Objective: Focused on observable behavior and clinical facts.
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Specific: Tied to treatment goals and interventions used.
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Timely: Written shortly after the session to ensure accuracy.
Purpose of Progress Notes
Well-written progress notes serve multiple purposes, including:
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Tracking patient progress over time.
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Supporting continuity of care between providers.
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Establishing medical necessity for services billed to insurance.
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Creating a legal record in the event of audits or disputes.
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Facilitating collaboration across multidisciplinary teams.
Clinicians who document consistently and thoroughly not only improve care but also protect themselves against liability and reimbursement issues.
Components of Progress Notes
There’s no single “right way” to write a progress note, but most should include:
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Session details: Date, time, service type, duration, and clinician name.
- Client presentation: Mood, behavior, appearance, and symptom report.
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Client response: How the patient engaged or reacted to treatment.
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Assessment: The clinician’s professional interpretation and clinical judgment.
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Plan: Next steps, homework, referrals, or treatment plan updates.
These components should align with the patient's treatment goals and reflect clinically relevant details, not opinions or speculation.
Download Our Guide to Writing Better, Faster Clinical Notes
Streamline your progress notes, avoid documentation pitfalls, and stay compliant with practical templates, note formats (SOAP, DAP, BIRP), and time-saving tips to write high-quality, defensible notes faster.
Progress Note Formats
There are several standardized formats clinicians can use when writing progress notes, including SOAP, DAP, and BIRP. Each format organizes clinical information differently, but they all aim to capture the same essential components: client presentation, interventions used, clinical assessment, and the treatment plan moving forward.
The best format often depends on your clinical setting, documentation requirements, and personal preference. What matters most is consistency, clarity, and compliance with standards for medical necessity and continuity of care.
Want a deeper look at common formats? Explore our guides on SOAP Notes, DAP Notes, and BIRP Notes.
Examples of What to Include in a Progress Note Template
Though we briefly mentioned the general structure of progress notes above, let's look at more specific progress note examples and what therapists and other behavioral health professionals must document.
Progress notes provide a clear, clinical record that allows behavioral health professionals to document findings, interventions, and treatment plans using objective medical facts. The required elements of a progress note can vary depending on factors such as payer requirements, state regulations, licensing board guidelines, or your practice setting. To ensure your documentation is both compliant and defensible, it’s essential to verify that your chosen note format and templates align with the standards set by these governing bodies.
In general, all progress notes should include a variation of the following:
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Date of Session and Start/End Times
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Client Name or ID
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Presenting Concern: Summarize the primary issue or focus of the session, as reported by the client or observed by the clinician. This could include symptoms, events, stressors, or goals discussed. Use client language when appropriate (e.g., “feeling overwhelmed at work”).
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Mental Status/Observations: Describe the client’s appearance, behavior, mood, affect, speech, thought content, orientation, and any other relevant mental status indicators observed during the session. Note any changes from prior sessions or safety concerns.
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Intervention(s) Used: List the therapeutic techniques, interventions, or modalities applied in the session (e.g., cognitive restructuring, mindfulness, supportive listening, safety planning). Be specific enough to demonstrate the medical necessity of the session.
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Client Response: Document how the client responded to the interventions — emotionally, cognitively, or behaviorally. Include insights gained, level of engagement, or resistance encountered. Use brief quotes if helpful.
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Clinician Assessment: Provide a clinical interpretation of the client’s current status and session progress. This may include diagnostic impressions, risk assessment updates, and evaluation of treatment progress. Keep this section objective and grounded in observable behavior or clinical tools.
- Link to Treatment Plan: Reference specific goals or objectives from the client’s treatment plan to show how the session content supports ongoing care. For example, note progress toward a goal (e.g., "Client continues to build coping strategies for managing social anxiety, aligning with Objective 2 in the treatment plan") or update the plan if new concerns arise. This strengthens documentation of medical necessity and demonstrates goal-directed therapy.
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Plan for Next Session: Outline the next steps in treatment, including follow-up topics, interventions to continue or modify, homework assignments, referrals, or changes in frequency. This helps maintain continuity of care and treatment plan alignment.
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Clinician Signature and Credentials
You can adapt this progress note template to suit your specific clinical approach, practice requirements, or EHR format.
Progress notes should reflect objective, clinically justifiable information — not personal opinions, assumptions, or unsupported judgments. Focus on what you directly observed and what was discussed during the session. Avoid including content that can’t be validated through clinical evidence or professional assessment. Exceptions may apply if the client discloses a critical incident, major life change, or any risk of harm to themselves or others, these should always be clearly documented.
Sample Progress Notes
Here are two examples of progress notes that demonstrate effective clinical documentation:
Sample Progress Note – Individual Therapy
Client reported increased anxiety related to an upcoming job interview. Used role-play to rehearse responses to common questions and cognitive restructuring to challenge negative self-talk. Client engaged actively and demonstrated improved confidence. Plan to review interview experience next session and introduce exposure hierarchy for social anxiety.
Sample Progress Note – Medication Management
Client reports decreased depressive symptoms on current dose of sertraline 50mg. No adverse side effects noted. PHQ-9 score decreased from 14 to 8. Will maintain current dosage and re-evaluate in four weeks.
These sample progress notes show how to be concise, objective, and clinically relevant.
Sample Progress Note
Date of Session and Start/End Times:
August 27, 2025 | 2:00 PM – 2:50 PM
Client Name or ID:
J.S. (Client ID #74839)
Presenting Concern:
Client reported ongoing stress and anxiety related to an upcoming family gathering, stating, “I’m already feeling tense just thinking about being around them.” She described difficulty sleeping and feeling easily agitated during the week. Identified goal: reduce physiological and emotional reactivity to triggering interpersonal situations.
Mental Status/Observations:
Client appeared well-groomed, alert, and oriented to person, place, and time. Speech was normal in rate and volume. Affect was congruent with stated mood (“anxious and frustrated”). Thought processes were logical and goal-directed. No suicidal or homicidal ideation reported. No psychotic symptoms observed.
Intervention(s) Used:
Provided psychoeducation on the fight-or-flight response and introduced diaphragmatic breathing as a grounding strategy. Engaged client in guided breathing exercise during session. Utilized cognitive restructuring to challenge anticipatory thoughts related to the upcoming event. Reviewed prior use of emotion regulation skills.
Client Response:
Client engaged well in session and reported the breathing technique helped her “feel a little more in control.” She was able to identify distorted thoughts such as “They’re going to judge everything I say” and collaboratively reframe them. Client appeared calmer at the end of the session and expressed willingness to practice new strategies at home.
Clinician Assessment:
Client continues to experience moderate anxiety with identifiable triggers. No risk concerns at this time. Presentation consistent with Generalized Anxiety Disorder (F41.1). Client is demonstrating increased insight and improved ability to apply emotion regulation techniques with clinician support.
Link to Treatment Plan:
Session content supports Objective 2 in the treatment plan: “Develop and apply at least two coping strategies to manage anxiety in social situations.” Client showed progress toward this goal by practicing and responding positively to diaphragmatic breathing and cognitive reframing.
Plan for Next Session:
Review client’s experience implementing breathing and thought-challenging techniques during the family gathering. Introduce visualization strategies if appropriate. Continue building emotion regulation skill set. No change to session frequency at this time.
Clinician Signature and Credentials:
L. Martinez, LCSW
Access Our Sample Notes Library
Get instant access to our full library of sample behavioral health notes, including Initial Evaluations, Progress Notes, Treatment Plans, and Discharge Summaries. We have note samples for psychiatry, therapy, case management, PRP, substance abuse, group therapy, couples therapy, and more!
How To Write Progress Notes Efficiently
To reduce charting time and improve clarity, follow these best practices when writing progress notes:
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Stay focused. Avoid documenting every word of the session. Highlight what’s clinically significant.
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Be specific. Use exact symptom descriptions, client quotes, and measurable outcomes.
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Write in the present tense. This promotes clarity and immediacy.
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Avoid jargon. Use standard clinical terminology others can understand.
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Document promptly. Write your notes right after the session to avoid forgetting key details. Using a menu-driven system like ICANotes means you can write your note during or between sessions.
If a session includes crisis intervention or a safety concern, make sure to document it thoroughly and clearly.
Best Practices for Writing Progress Notes
To ensure your progress notes are audit-ready, clinically meaningful, and efficient to produce, remember these best practices:
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Keep your notes aligned with the treatment plan.
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Always include your signature and credentials.
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Avoid abbreviations unless they are widely accepted.
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Store notes securely in accordance with HIPAA guidelines.
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Document refusals, noncompliance, or safety concerns clearly.
Progress notes aren’t just for your records, they’re part of a client’s ongoing care and may be reviewed by supervisors, insurers, and legal entities.
Why You Should Use EHR Software for Progress Notes
Depending on how many patients you see and how frequently, you can end up spending several hours every day writing your progress notes. Not to mention, handwritten paper progress notes can present many issues, such as getting lost or damaged. Paper progress notes will also take you much longer to complete than electronic notes.
Research shows that clinical documentation contributes heavily to staff burnout because it takes significant time that therapists and other mental health professionals could instead spend with patients. One study found that clinicians welcome a serious redesign of documentation processes to restore autonomy, eliminate the number of actions that do not add value and return time to staff for more essential care activities.
By introducing EHR software, you can lift the burden of documentation with these benefits:
- Making your notes legible, easy and quick to read
- Reducing documentation errors or missing information
- Preventing lost revenue due to under-coded notes or claims being rejected
- Reducing time spent on documentation and record-keeping
- Leveraging clinical progress note templates for consistency
- Increasing your peace of mind that your notes will comply with regulations and pass an audit.
Progress note software built into your electronic health record (EHR) system can drastically reduce documentation time and improve compliance. Key features to look for in EHR progress note tools include:
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Auto-populated session details
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Prebuilt templates for various visit types
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Click-to-add clinical interventions
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Built-in risk assessments and outcome measures
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HIPAA-compliant cloud storage
By reducing manual entry and repetitive tasks, progress note software helps you focus more on clinical care and less on paperwork.
Frequently Asked Questions
How ICANotes Helps Clinicians Write Better Progress Notes
ICANotes is a behavioral health EHR platform purpose-built to make writing mental health progress notes fast, accurate, and compliant. Our intelligent charting features include:
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Specialty-specific templates for mental health documentation
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Structured, menu-driven charting that reduces typing
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Built-in compliance tools that support medical necessity
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Group therapy notes that auto-populate across charts
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EHR-integrated billing, scheduling, e-prescribing, and telehealth to streamline workflow
With ICANotes, you can spend less time writing and more time treating. Whether you’re documenting for therapy, psychiatry, or medication management, our progress note software adapts to your workflow and helps you stay on top of every session.
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Dr. October Boyles
DNP, MSN, BSN, RN
Dr. October Boyles is a behavioral health expert and clinical leader with extensive expertise in nursing, compliance, and healthcare operations. With a Doctor of Nursing Practice (DNP) and advanced degrees in nursing, she specializes in evidence-based practices, EHR optimization, and improving outcomes in behavioral health settings. Dr. Boyles is passionate about empowering clinicians with the tools and strategies needed to deliver high-quality, patient-centered care.