There is no one size fits all method to completing progress notes, and they can be written in a number of ways. As you get to know your clients and their therapeutic needs, you'll figure out the best method for your practice. But to start, here's a breakdown of therapy progress notes, and what to include in yours.

Mental health progress notes are what clinicians use to document the details of every session, focusing on the client's condition coming in, as well as what transpired during the clinician's interaction with the client. Clinicians have a legal and ethical responsibility to document each treatment episode as part of the client's official medical record. 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.

There are a lot of different ways you can write progress notes for therapy. Many clinicians find it ideal to utilize electronic health record systems in order to speed up the process by utilizing clickable checkboxes and fillable templates that hit all of the important elements required for documentation. Electronic notes also have the added benefit of being consistently legible, which is a major requirement of progress notes.

Others prefer to have a physical paper note, as they can complete some of it in-session. 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.

A hybrid approach might involve some handwritten notes to assist you in remembering some key details when you complete an electronic note later. 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

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