Best Practices for Mental Health Progress Notes

Most of us did not go into the mental health field because we love administrative tasks, and yet we find ourselves spending a tremendous amount of our professional lives completing progress notes and other forms of documentation.

If you’re a therapist or other mental health provider, you’re probably used to the idea of writing progress notes after each visit. And there’s a good reason for this.  

Progress notes accomplish multiple purposes, including: 

• Helping you to keep track of each client and their treatment.
• Coordinating care by communicating pertinent information to other members of the care team.
• Maintaining a paper trail for agency audits and quality assurance. 
• Complying with your professional obligations.
• Billing for your services.

What Are Mental Health Progress Notes?

The exact content of a progress note will vary depending on state, local, and organizational requirements. Yet, most mental health providers, including psychologists, social workers, marriage and family therapists, and others, write progress notes after each visit that describe:

• Treatment interventions (e.g. cognitive restructuring, collaborative problem solving, mindfulness techniques, stress management, empathetic validation). 
• Client response.
• Notable changes since the previous visit. 

Types of Mental Health Progress Notes

Not all mental health progress notes are equal. A family and children’s services worker in California will have different documentation requirements than a clinician conducting assessments for SUD treatment in Wisconsin or a Jungian analyst in Pennsylvania.  

What’s essential is that your notes are compliant with local, state, and federal laws as well as your professional association and licensing board. They also must meet your organizational and contractual requirements, document your care and decision-making in high-risk situations, and promote collaborative and cohesive care with other members of the care team.  

Mental Health Progress Notes Templates

Two of the most common mental health progress notes templates are the BIRP and SOAP methods.

BIRP Progress Notes

The BIRP method offers a straightforward template to include essential visit information while breaking it into sections so it’s easier to follow. 

BIRP is an acronym that stands for: 

• Behavior, or how the client presents at the visit, their current issues, and your subjective and objective observations. 
• Interventions, or the methods used to work with the client towards treatment goals. 
• Response, or how the client responded to the interventions in the session.
• Plan, or what is to happen after the visit including referrals, any between-session homework, emergency or safety plans, and when you will next follow up or meet.  

Below is an example of a BIRP progress note: 

Behavior: Client reported frequent experiences of becoming infuriated, anxious, and dysregulated by “the slightest annoyance.” She fidgeted throughout the session. Her speech and thought content were clear, though her thought process presented as fragmented, tangential, and filled with loose associations congruent with her PTSD diagnosis. Denied SI/HI. 

Interventions: Practiced visualization and grounding techniques to untangle different emotions and learn how to self regulate. Completed the PCL-5 as a rating scale to track progress and as a clinical tool to implement grounding techniques in moments of heightened distress. Scored a 45.  

Response: Client expressed distress and frustration when reviewing a traumatic event from her past. She responded by noting the tightening in her chest and jaw as a sign of frustration and a “vibrating feeling” in her chest that indicated distress. She stated that she felt these dissipate as she practiced square breathing and 5-4-3-2-1. 

Plan: Continue to practice grounding techniques and tease apart challenging feelings while channelling aggression in appropriate directions. Meet at the regular time next week. 

SOAP Progress Notes

Originally developed for use in healthcare, the SOAP method is another common template for progress notes that some therapists and mental health providers use. SOAP is an acronym that includes four parts:

• Subjective, or a description of the current state of the client including their feelings, affect, performance, and observations from third parties. 
• Objective, or measurable outcomes about your client’s progress or performance.
• Assessment, or your analysis and interpretation of the client’s progress. 
• Plan, or what is to happen after the visit including referrals, any between-session homework, emergency or safety plans, and when you will next follow up or meet.  

The following is an example of a SOAP progress note: 

Subjective: Client was alert and engaged in the session. She reported frequent experiences of becoming infuriated, anxious, and dysregulated by “the slightest annoyance” throughout the previous week. Grounding techniques allowed her to identify the emotion early on and self regulate. 

Objective: Scored a 45 on the PCL-5. Affect was appropriate if slightly constricted. Speech was coherent and normally paced and thought content was clear. Thought process presented as fragmented, tangential, and filled with loose associations congruent with her PTSD diagnosis. Denied SI/HI. 

Assessment:  Client reports a decreased frequency and intensity in her experiences of anger and anxiety, which are linked to multiple traumas that she experienced in childhood, and which continue to impair her organizational capacities and relational responses to family members and colleagues. Client is reflective, insightful, and motivated in treatment. She’s interested in examining her emotions and behaviors, and committed to working on emotion regulation. 

Plan: Continue to practice grounding techniques and tease apart challenging feelings while channelling aggression in appropriate directions. Meet at the regular time next week.  

How to Write Progress Notes – 5 Common Mistakes to Avoid

Despite varying laws, regulations, and requirements, there are some general rules of thumb that you can follow when writing progress notes for mental health visits. 

Below are 5 common mishaps that you can avoid to ensure that your notes are as high quality as the care that you are providing.   

1. Don’t Rely on Subjective Statements

It’s generally better to be specific and include objective details in addition to subjective descriptors. 

You might be tempted to write things like, “client is a good mother,” or “client has anxiety.” However, the former is an opinion, rather than a fact, and the latter is far too general. Instead, consider writing, “client is bonding with infant and able to read and respond to infant’s cues.” Or, “client experiences excessive worry, restlessness, and irritability.” In addition, don’t hesitate to use descriptive or illuminating quotes directly from the client. 

When your notes are based on facts, they’re more valid with licensing boards, the court system, and other involved organizations. It also helps other members of the care team to access a clear picture of what is going on with the client and how to best support them. 

2. Avoid Excessive Detail 

There’s a fine line between including enough detail and writing long, drawn-out descriptions that are overindulgent or express far more than is necessary. Consider whether your long paragraph can be expressed equally well in one or two sentences. 

This doesn’t mean that you should cut corners or skip relevant information. And one caveat is that you should thoroughly document your process in managing professional or ethical dilemmas as well as high-risk situations like suicidality. Be sure to include the steps you took in these circumstances as well as clear and careful reasoning behind how you chose to manage it. 

3. Know When to Include or Exclude Information 

To protect the privacy of people who have not consented to therapy or other mental health services with you, avoid naming or identifying third parties when possible. If your notes are read by another clinician, subpoenaed, or even read aloud in court, you want to be sure that you’re not disclosing something or putting someone else at risk unnecessarily. 

On the flip side, if a client expresses a wish that you leave out certain information in your progress notes, it’s important to have an open conversation with them about what you can omit and what needs to be included depending on legal, contractual, and ethical requirements. 

In some cases, you can complete progress notes with the basic and necessary information in the client’s record while also creating separate secure psychotherapy notes for yourself.

4. Don’t Forget to Include Client Strengths

No matter how dire your situation is, everyone has strengths. These can include something that’s going well at the moment, community support, or personal resilience. It’s important to include client strengths to paint the full picture of their experience and to ensure that you recognize and build on their strengths in treatment.

5. Save Paper, Time, and Hassle by Documenting Electronically 

Two key factors to pay attention to with progress notes are to ensure that they are legible and secure. These are ethical and legal issues that you don’t want to miss. For example, HIPAA includes a security rule guarding against unintended disclosure or destruction of your notes. Digital notes in a secure EHR or electronic documentation software meet these two requirements while eliminating your need to keep track of and safely store paper charts. In addition, checkboxes and embedded mental health progress note templates, like BIRP or SOAP, also encourage efficiency, consistency, ease of note retrieval, and care coordination.

*Kate Dubé is a Licensed Clinical Social Worker (LCSW) and health & wellness writer in Berkeley, California. You can find her at https://www.linkedin.com/in/kate-dube.