Therapy Progress Notes: Templates & Best Practices

Therapy progress notes (also called session notes, psychotherapy progress notes, or mental health progress notes) are the clinical record of each individual therapy or counselling session. They document what occurred, the patient's presentation, the clinician's assessment of progress, and the treatment direction going forward.

What Are Therapy Progress Notes?

Progress notes are required by provincial licensing colleges in Canada, state licensing boards in the US, and most insurance payers. They are part of the patient's permanent health record. Writing clear, specific, and contemporaneous notes is both a professional and legal obligation.

Progress notes are distinct from psychotherapy notes (or process notes), which are the clinician's private reflections stored separately from the medical record with stronger privacy protections. Progress notes document the billable service.

What to Include in Every Progress Note

1. Patient Presentation: Mood, affect, appearance, behavior, speech, and mental status.
2. Presenting Concerns / Session Focus: What the patient brought to the session: current stressors, significant life events, etc.
3. Standardized Assessment Scores: When administered, include the score and severity classification (e.g., PHQ-9, GAD-7).
4. Interventions Used in Session: Name the specific therapeutic technique(s) used (e.g., cognitive restructuring).
5. Progress Toward Treatment Goals: Explicitly state whether the patient is progressing, stable, or deteriorating on active goals.
6. Risk Assessment: Every note must explicitly document suicide/self-harm risk, even when negative.
7. Plan: Next session date, homework assigned, and any coordination with other providers.

Common Progress Note Formats

• SOAP Notes: Subjective · Objective · Assessment · Plan. The most widely used format; provides a clear home for assessment scores.
• DAP Notes: Data · Assessment · Plan. A simplified format combining patient report and observations into one Data section.
• BIRP Notes: Behavior · Intervention · Response · Plan. Focuses on the clinician's interventions and patient response.
• Narrative / Freeform: Paragraph prose without fixed sections. Harder to audit but accepted by most boards.

Therapy Progress Note Template

Session Info Date: date | Session #: n | Duration: mins | Modality: Individual / Group | Format: In-person / Telehealth

Presenting / Session Focus (Subjective / Data) Patient reports mood/affect. Sleep: hrs/quality. Significant events: list. Homework status: status. Session focus: topic.

Observations & Assessment Scores (Objective)Assessment scores, e.g., PHQ-9 = 11 (Moderate). Patient presented on time. Appearance appropriate. Affect congruent. Thought process linear. Risk: denies SI/HI.

Clinical AssessmentDx. Clinical impression: summary. Progress toward Goal #: improved / stable / deteriorated. Risk level: Low / Moderate / High.

Interventions Used in SessionSpecific techniques, e.g., cognitive restructuring. Patient engaged well.

Plan Next session: date. Homework: specific task. Repeat assessment at next session.

Including Assessment Scores in Progress Notes

Standardized assessment scores transform a progress note from a narrative impression into a data-rich clinical record. When documented in every relevant note, they create a longitudinal trend that makes treatment response, or treatment failure, visible.

Best Practices:

• Report score, severity band, and change from last administration.
• Interpret the change in the Assessment section.
• Flag high-risk item scores explicitly (e.g., PHQ-9 item 9).

Frequently Asked Questions

What should be included in a therapy progress note?

A complete note includes: patient concerns and mood, clinician observations, assessment scores, session content/interventions, progress toward goals, risk assessment, and the plan for the next session.

What is the difference between a progress note and a psychotherapy note?

Progress notes document billable services and are part of the medical record. Psychotherapy notes are private reflections stored separately and have stronger privacy protections.

How soon after a session should a progress note be written?

Most licensing standards require progress notes within 24 hours of the session to ensure accuracy and defensibility.

What is the best note format for therapy progress notes?

The most widely used formats are SOAP and DAP. SOAP is often preferred when tracking standardized assessment scores regularly.