Complete a Psychotherapy Progress Note

TherapyNotes' Psychotherapy Progress Note template is based on the SOAP format and pulls information from previous notes to ensure efficient, rich documentation.

Psychotherapy Progress Notes are generated when Therapy Session is selected as the Appointment Type. Once a scheduled Therapy Session begins, TherapyNotes will create a To-Do list item prompting the clinician to complete the corresponding Progress Note. To learn more about creating notes and note writing tools in TherapyNotes, read Create a Note.

Role Required: Clinician, Intern, or Clinical Administrator

Note Header

The note header automatically fills in information for the clinician, client, and appointment, including relevant supervision information, client insurance, and service code. You can also document who attended the session, such as when working with collateral contacts or with family members when the identified client is not present. To edit information in the note header such as the Note Title or Service Code or to add information such as add-on codes, click anywhere on the note header or click Edit in the upper right corner.

Diagnosis

The Diagnosis section will automatically populate a DSM-5 diagnosis code and description based on the information entered in the client's Treatment Plan or most recent note. These fields also feature searchable DSM-5 diagnoses, allowing you to easily edit existing or add additional diagnoses.

Current Mental Status

Progress Notes contain a full Current Mental Status exam. Use our one-click autofill options ( All Normal or All Not Assessed) to simultaneously fill each of the fields, click in each field to select from a list of common responses, or enter your own information in each field.

Risk Assessment

Select the Client denies all areas of risk checkbox to indicate that the client denied all areas of risk and that your clinical assessment did not find any contrary indications. 

If your client does present with an area of risk, click in the Area of Risk field to select from a list of common areas of risk or type your own. Next, select the appropriate Level of Risk and if the client has Intent, Plans, and Means to Act. Each of these fields are required for each area of risk documented. Optionally, you can enter Rick Factors and Protective Factors. Click the appropriate field, the select as many options from the list as apply or type your own factors. If your client presents with more than one area of risk, click Add Area of Risk at the bottom to add another set of fields to document each area separately. Use the arrows in the top right of each Area of Risk to order these in your note, or click the X to remove an area of risk entirely.

Medications

List any medications the client is currently taking. Since medications do not change frequently, consider using the History button to see what has been entered into the Medications field on previous notes. To pull this information into the current note, click the Use button. Review and edit the information as necessary.

Symptom Description and Subjective Report

Document the client's experience of symptoms and challenges since the last session. Symptom Description and Subjective Report may contain information told to the clinician and can include direct quotations of clients such as, "These visits are really helping me to strengthen my parenting" or "I think that these coping strategies are really working; I was able to concentrate at work all day."

The information in this field may answer questions such as, "How is the person is doing?", "What is the client's perspective about the problem?", or "What is the client’s opinion of the therapeutic intervention or service?" In this field, you may also document any information about the client given to you by someone else that you cannot verify but has an impact on the session or services.

Objective Content

Report the measurable and observable information that you obtain during the session. Here, you may report behaviors that you observe, not just the behaviors you are targeting.

There are two types of objective data: the provider’s observations and outside written materials. This is the section to document that which can be seen, heard, smelled, counted, or measured. You can document observations such as the mood and affect of the client here as well. The Relevant Content field is also where you can document specific information about conversations or interventions used during the session. If you want to take notes about conversations in the appointment, or document private thoughts or impressions, you may want to use a Process Note as well.

Interventions Used

Select the appropriate checkboxes to document the interventions utilized during the session. This can assist with ensuring that you meet documentation requirements for some payers by clearly delineating specific therapeutic approaches.

Your interventions list is customizable to make it easy to list the interventions you use most frequently. Click Customize to add or delete custom interventions.

Treatment Plan Progress

Document progress towards each of your treatment plan objectives. Click each Progress field to select from a list of common responses, or enter your own assessment. This enhances the closed-loop documentation approach, as you specifically link interventions in the session to objectives identified on the client's Treatment Plan.

Additional Notes / Assessment

This field is not a necessary component of each note. However, it is often useful to document the client’s response to your interventions, your assessment of client functioning and progress, medical necessity for ongoing treatment, or your case conceptualization.

Some payers also have specific requirements for information to be contained in notes. This is the appropriate field to document those requirements.

Plan, Recommendation, and Prescribed Frequency of Treatment

The Plan is the clinician’s plan of action, if any, and includes recommendations for the client or collateral contacts, therapeutic interventions, and a prognosis (poor, guarded, fair, good or excellent). Use the Recommendation radio buttons to document your treatment recommendations. Enter how often you plan to see the client going forward in the Prescribed Frequency of Treatment field.

Sign and Save

Note: In order to save a Psychotherapy Progress Note, you must enter the Diagnosis, Safety Issues, Objectives, Plan, and Recommendation. All other fields are optional.

Once you have completed your Progress Note for the session, select the Sign this Form checkbox to electronically sign the note and click the Create Note button. Electronic signatures are captured in accordance with appropriate requirements. Multiple factor authentication is required to identify the user signing the note. The application automatically captures the timestamp for the signature as well. Electronic signatures cannot be edited or modified. If the document is placed in draft mode and then re-signed, the signature on the note will reflect the most recent electronic signature captured. You can view other signatures, including the timestamp of the first signature on the note, using the Note Revision History. All actions related to note signatures are captured in the activity log for the practice.

To save an unfinished Progress Note, leave Sign this Form unchecked and click the Save Draft button. You may access your draft Progress Note later from your To-Do list or click Patients > Patient Name > Documents tab.

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