Tips for Writing Better Mental Health Progress Notes (with Examples)

Progress notes document a patient's journey through treatment and serve as a vital tool for healthcare professionals. While their significance is pretty self-evident, there are always ways to improve and streamline your approach to write your progress notes in a more effective way.

Let's discuss some guidance around how to make your progress notes beneficial for you and your patients, including common pitfalls and practical tips for improving the clarity and efficiency in your progress notes. 

The Importance of Progress Notes

‍Progress notes provide detailed records of a patient's treatment journey – they capture key information about each encounter, including assessments, interventions, and outcomes. These notes act as a critical communication tool among healthcare providers, and keep everyone involved in a patient's care informed and aligned with common goals.

As for the benefits of progress notes, well-written progress notes improve patient care by helping providers make informed decisions, monitor progress, and adjust treatment plans. Generally, accurate and thorough documentation can offer legal protection for healthcare professionals.. In addition, when working as a part of a collaborative treatment team, progress notes ensure continuity of care by facilitating a smooth transition between providers. They offer a comprehensive view of a patient's history, current status, and future needs.

Common Pitfalls in Writing Progress Notes

‍Progress notes play a vital role in documenting a client's journey through therapy, but therapists often encounter several common mistakes. Let's take a closer look at these pitfalls and how to avoid them.

Lack of Clarity

• Using vague language: Ambiguous or unclear language can lead to confusion and misinterpretation. Aim for specificity and precision in your notes without going into too much detail.
• Failing to provide context: Without proper context, progress notes can be difficult to understand. Include relevant background information and connect each note to the client's overall treatment plan.

Incomplete Information

• Missing critical details: Omitting key information, such as the client's presenting concerns, interventions used, or homework assigned, can hinder the continuity of care. Make sure your notes are comprehensive and capture all important elements of the session.
• Neglecting objective observations: Progress notes should include both subjective reports from the client and objective observations made by the therapist. Don't forget to document observable behaviors, body language, and other relevant factors.

Overuse of Jargon

• Making notes inaccessible to others: While technical terms and abbreviations may be familiar to you, they can be confusing for other professionals or clients who may access the notes. Use clear, concise language and industry-standard abbreviations that can be easily understood by all readers.
• Failing to explain acronyms: If you must use acronyms, make sure to define them the first time they appear in your notes. This ensures clarity and prevents misunderstandings.

Inconsistency

• Variability in note-taking styles: Inconsistent formatting, structure, or content across progress notes can make it difficult to track a client's progress over time. Develop a standardized template or format for your notes to maintain consistency and clarity.
• Failing to maintain a regular schedule: Inconsistent or sporadic note-taking can lead to gaps in documentation and hinder the ability to monitor a client's progress effectively. Establish a consistent routine for writing and updating progress notes.

Tips for Writing Better Progress Notes

Tip 1: Be Concise
Therapy progress notes should focus on the most critical information related to the session. The goal is to summarize the essence of the session without overloading the note with irrelevant details. Avoid long narratives, superfluous background information, or repetitive descriptions of prior sessions unless they directly impact the current session's work.

• How to apply it:some text
  • Start with a clear structure: Identify the most important areas of focus for each session (e.g., presenting issue, key interventions, client response, next steps).
  • Stick to the facts: Summarize symptoms, interventions, and the client’s response concisely. For example, instead of describing every minute detail of a client’s background or session history, provide only the critical updates that impact treatment decisions.
  • Be specific and to the point: For example, instead of writing "The client is still experiencing significant anxiety and difficulty sleeping," write "The client reports feeling anxious daily, particularly in the evenings, and experiences difficulty falling asleep 4-5 nights a week." This gives clear data without excessive elaboration.
• Example:
  Too wordy:
  "The client has been feeling really anxious for the last several weeks. She states that it's been affecting her work and her ability to sleep. She feels stressed and restless, especially in the evenings before going to bed, and reports that it has been harder for her to focus at work. She is very frustrated with these symptoms and wants to find ways to feel better."
  Concise version:
  "The client reports increased anxiety, particularly in the evenings, affecting her sleep and work focus. She is seeking strategies to manage these symptoms."

Tip 2: Use Clear Language
It's important to write in language that is clear and accessible to anyone reading the progress note, including non-mental health professionals. Avoid using jargon, acronyms, or overly technical language that could confuse others. If using a technical term is unavoidable, explain it in simple terms.

• How to apply it:some text
  • Write for clarity: Use everyday language to describe client symptoms, interventions, and progress. For instance, instead of "client demonstrates avoidance behaviors related to social situations," you could write "client avoids social situations due to fear of judgment or embarrassment."
  • Clarify any technical terms: If you  use acronyms or abbreviations that are not commonly used or known, include a brief explanation: “The client is participating in Attachment Focused EMDR (AF-EMDR) to address developmental trauma leading to difficulty with trust in relationships.”
  • Be mindful of your audience: Consider that these notes may be read by colleagues, supervisors, or future clinicians who might not be familiar with the specific clinical terms you use.
• Example:
  Technical term: "The client presented with symptomology consistent with dysthymia."
  Clearer version: "The client shows signs of chronic low mood, irritability, and expressed a sense of hopelessness. ."

Tip 3: Maintain Consistency
Using a consistent format across all progress notes helps maintain clarity and ensures that all necessary information is included. A standard format allows for efficient documentation and makes it easier for any reader to find relevant information, whether it's for continuity of care or future reference.

• How to apply it:some text
  • Create a template or checklist: Develop a set structure that includes key components such as date, session objectives, interventions, client response, and next steps. By following the same outline for each note, you will ensure that nothing important is missed. A pre-existing note template may also be used such as GIRP notes or DAP notes.
  • Use headings or bullet points: This enhances readability and ensures clarity in organizing your thoughts. For example: Session Focus, Interventions Used, Client Response, Plan.
  • Be consistent with language and abbreviations: If you use specific abbreviations (e.g., "MDD" for major depressive disorder), make sure they are defined once and consistently applied throughout. Avoid introducing new abbreviations without explanation.
• Example of a consistent format:some text
  • Date & Time of Session
  • Session Focus (e.g., anxiety management, trauma processing)
  • Key Interventions (e.g., mindfulness, exposure therapy, cognitive restructuring)
  • Client's Progress/Response
  • Plan for Next Session/Next Steps
  • Homework/Assignments (if applicable)

Tip 4: Include Relevant Details
While brevity is important, a therapy progress note must still include all relevant details that help inform treatment decisions. These include the client's presenting concerns, any interventions or strategies used, the client’s response to those interventions, and any updates that impact treatment planning.

• How to apply it:some text
  • Don’t skip critical information: For example, if a client is reporting increased anxiety or depressive symptoms, it’s important to document these changes in mood or behavior to adjust the treatment plan accordingly.
  • Document client progress and setbacks: Be sure to include specific examples of progress or challenges, such as improvements in coping skills or difficulties with applying strategies outside of sessions.
  • Record any new issues or concerns raised: If a client brings up new stressors or events (e.g., a recent loss, trauma trigger, or medication change), these should be documented for future sessions.
• Example:
  Incomplete:
  "Client reports feeling stressed at work."
  Complete:
  "Client reports increased stress at work due to a recent change in management. She reports she feels unsupported and is finding it difficult to focus on tasks, which is exacerbating her anxiety."

Tip 5: Be Objective
Progress notes should be grounded in observable facts rather than personal judgments or opinions. This helps ensure that the notes are accurate, unbiased, and useful for anyone who may need to review them in the future. Objectivity also reduces the risk of misinterpretation and enhances the professional quality of documentation.

• How to apply it:some text
  • Use neutral language: Stick to factual descriptions such as "client appeared anxious during the session," rather than "client was visibly nervous and overreacting."
  • Document observable behaviors: Describe actions, statements, and non-verbal cues, such as "client avoided eye contact," instead of general statements like "client seemed uninterested."
  • Report the client’s perspective: Even if the client is upset or distressed, avoid making assumptions about why they are feeling that way. Instead, document their statements in their own words.
• Example:
  Subjective:
  "The client seems to be in denial about her depression."
  Objective:
  "The client expressed difficulty acknowledging her depressive symptoms, stating, 'I just don’t feel like I’m that depressed.'"

Tip 6: Use Active Voice
Writing in an active voice makes progress notes more direct, engaging, and easier to read. Active voice emphasizes the subject of the sentence and makes it clear who is performing the action, rather than burying the action in passive language. This is important for maintaining clarity and ensuring that the note reflects the client’s active participation in their own treatment.

• How to apply it:some text
  • Use the subject-verb-object structure: For example, instead of writing “The intervention was completed by the therapist,” write “The therapist completed the intervention.”
  • Make the action clear: Instead of passive constructions like "Progress was made by the client," use active phrasing like "The client demonstrated progress in managing anxiety using coping strategies."
  • Avoid overly complex sentence structures: Keep sentences simple and direct. For example, rather than saying, “The client was feeling upset after having talked about her recent loss,” wrote “The client felt upset after discussing her recent loss.”

Example:
Passive:
"The coping strategy was implemented by the therapist."Active:
"The therapist implemented the coping strategy during the session."