How To: Complete a Progress Note

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TherapyNotes' Psychotherapy Progress Note template is built off the SOAP format and pulls information from previous notes to ensure efficient yet rich documentation.

Psychotherapy Progress Notes are connected to appointments with Therapy Session selected as the Type. Once a scheduled Therapy Session begins, TherapyNotes will generate a To-Do list item to create the corresponding Progress Note. To learn more about creating notes and note writing tools in TherapyNotes, read How To: 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. 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.

Patient Presentation

Patient Presentation acts as a miniature 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.

Safety Issues

Select the applicable checkboxes to indicate any safety issues. If Suicidal Ideation or Homicidal Ideation are selected, or if another safety issue is entered in the Other field, document whether the client has the intent, plan, and means to act on these ideations using the radio buttons and Describe field that appear.

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.

Relevant 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

Objectives

Document progress towards each of your treatment plan objectives. Click in each Objectives 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 Regarding Goals and Objectives

This field is not a necessary component of each note. However, it is useful to document the client's performance in the session or the session itself in descriptive terms. Here, you may also write your clinical impressions (how you would label the client’s behavior and the reasons, if any, for this behavior).

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.

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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