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How to Write Progress Notes

As a therapist, progress notes are necessary for you to track your patient's progress and ensure they are receiving effective treatment options. Progress notes contain critical information about an individual, couple, or group therapy session you can reference to adjust or modify your methods as needed.

However, if your notes are often illegible, confusing, unorganized, or not detailed enough, it can be difficult to translate them later and may cause you frustration and wasted time. To provide effective and efficient care, it's critical to keep your progress notes organized, specific, relevant, and concise. Below, we'll examine the differences between progress and psychotherapy notes, documentation styles you can use, and how implementing EHR software can enhance your note-writing processes.

Table of Contents

How Progress Notes Differ From Psychotherapy Notes

Examples of What Makes Up Progress Notes

Documentation Styles

How to Write Effective Progress Notes
Common Terminology and Interventions to Reference

Best Practices for Writing Progress Notes

Why You Should Consider Using EHR Software for Progress Notes

Writing Better, Writing Faster

Get Instant Access to Our Guide to Efficient Clinical Notes in Behavioral Health.

How Progress Notes Differ from Psychotherapy Notes

Though you may have heard progress notes and psychotherapy notes used interchangeably, they have a few significant differences in their purpose, formatting and who has access to them. For starters, psychotherapy notes are generally for a therapist or other mental health professional alone to view and reference to help remember patient encounters. These are your personal notes to use as needed in individual, couple, or group counseling sessions which may contain your unique interpretations and impressions of patients.

The Health Insurance Portability and Accountability Act (HIPAA) regulates psychotherapy notes . These notes may not be included in any other documentation about your clients, such as billing or medical information, and cannot be shared with anyone else, including the client, unless in some cases where you may need their permission to share them. Psychotherapy notes should never contain information about your patient:

Results of clinical tests
Treatment plan details

Progress notes, on the other hand, have a much more formal structure and include your client's medical and treatment plan details. These notes help therapists and other treating practitioners stay updated on their work with a patient and help inform insurance companies of the efficiency of your methods.

You may have to write your progress notes according to specifications by the insurance company, but these notes can also protect you if questions arise about your quality of care. Other behavioral health providers working with your client, the client themselves, and their family members are generally allowed to view your progress notes.

Progress notes serve as a communication tool between you and other clinical staff about your patient's overall care and treatment plan. With consistent, updated notes, you can focus more easily on your patient's progression and streamline your billing and reimbursement processes. These notes are also protected under the HIPAA Privacy Rule , so it's important to know what information is protected, like individual identifiers.

What are progress notes? Progress notes definition

Though we briefly mentioned the general structure of progress and psychotherapy notes above, let's look at more specific progress note examples and what therapists and other behavioral health professionals must document.

Progress notes serve as a record that allows clinicians to communicate findings and plans through medical facts regarding a patient's condition. The specific elements you must include in your progress notes may depend on the insurance company, your state requirements, your licensing board, or your professional organization or practice. It's critical to check with these channels and confirm your note formats and templates are compliant.

In general, all progress notes should include a variation of the following:

Demographic information: You may include your client's name, date of birth, start and end times of each session, and your signature.
Description of client behavior: Describe your client's behavior, appearance, mood, symptoms, diagnosis, changes to medications, and a safety assessment. You can also use a mental health status checklist to help consolidate this area of your notes.
Treatment plans: List the treatment modalities, recommendations, coping skills, and assignments you used during the session. You should also include your client's response and progress toward their established goals and what you plan to work on in the following session. Note any referrals you've made for the client or if you've collaborated with other mental health professionals regarding your client.

Your progress notes should never include anything that cannot be validated or justified through clinical evidence and investigation, so there should be no references to your subjective opinion, judgments, feelings, or hypotheses. Your progress notes should only contain precisely what you observe through your professional opinion and what was discussed between you and your client during your session. In some cases, you may need to make an exception in your notes, such as if your client brings up a critical incident, significant changes, or risk of harm to themselves or others.

Here's an example of patient symptoms/behaviors in a progress note:

"Jane denied having suicidal thoughts in the past week. She reported feeling anxious and sad most of the time. She received a write-up at work this week. She expressed frustration with her management. Jane was tearful as she talked about feeling incompetent at her job and not understanding how she can progress. She noted that after speaking to her manager about the write-up using a recommended therapeutic exercise, he was more understanding and offered to help improve her training".

Because there are many different ways you can conduct your notes to meet your needs, let's look at four different documentation styles therapists commonly use to keep their progress notes organized, relevant and concise. While you can use these documentation formats for other types of notes, we'll focus on structuring them to fit progress note criteria.

In DAP notes, you will construct your progress notes in a Data, Assessment, and Plan format. These notes should include:

Data: Include descriptions of major events or topics discussed and interventions you provide. Collect objective and relevant information, including behaviors, actions, and descriptions from the patient that may affect their treatment methods.
Assessment: Your observations of your client's status and functioning, including risk status, are considered the assessment. Analyze the data you've collected and include your client's response to the methods you use during the session.
Plan: List any plans for the future or changes to your client's treatment plan, such as recommendations, alternative treatments, homework assigned, and additional resources.

DAP notes may also sometimes be referred to as DARP notes, which include the acronym for Response. In these notes, you will fill out the Data, Assessment, and Plan section as usual, but include a “Response” section after your Assessment. This section will include your clinical rationale and reasoning for providing specific treatment based on your most recent interactions with your client.

The four sections of the SOAP method include:

Subjective data: Though progress notes should remain free of your unsourced personal opinions and judgments , such as describing a client as “hysterical," you may be able to list a patient's direct quotes, experiences, feelings, thoughts, or observations.
Objective data: Note your patient's general and mental health status and other relevant details from your therapy appointment. List your descriptions as if you were performing a physical exam of your client, including their body language or other facts.
Assessment information: After collecting your subjective and objective details, provide your professional interpretation and a summary of your patient's diagnosis. Include your conclusion about the interventions and goals you addressed during the session.
Plan: List any details regarding the next steps or adjustments to your patient's treatment plan. Note any follow-up information, referrals, lab orders, review of medications, and your plan for your next therapy session.

Like SOAP notes, BIRP notes involve four different sections to help therapists and mental health professionals document patient progression and treatment. However, BIRP notes focus more on patient behavior . The four sections of BIRP notes should include:

Behavior: Document the chief complaint or primary problem the patient presents, including their actions, willingness to participate, and observations of their behavior.
Intervention: Provide a detailed account of the methods you used to intervene and help your patient reach their treatment goals, such as the questions you asked and decisions you made to adjust treatment or techniques.
Response: Describe your patient's response and reaction to your intervention techniques and treatment methods. Record what they said, the questions they asked, and whether they changed their minds about therapy.
Plan: Create a plan for your next session with the patient and note the time and date when you will meet again. Note what you plan to discuss in the next appointment and whether you assigned any exercises for your patient to complete before their next session.

How to Write Effective Progress Notes

Here is a step-by-step guide for progress notes that can help ensure you have all the important details and information needed to create more effective documentation:

Note header: Write a brief review of session information, such as the practitioner and patient name, the time and date of the appointment, and relevant service or billing codes.
Diagnosis: Include any DSM-5 or ICD-10 codes if you have diagnosed your patient with a mental health condition.
Patient Appearance: Provide an objective description of how your patient appears, including their behavior or cognitive functioning.
Safety concerns: Note any critical information regarding your patient's safety and well-being, including risks.
Medications: Psychiatrists may only need to use this section, but as a therapist, you can list a patient's medications and their relationship with them, such as if they feel they're effective.
Symptom description report: Include direct quotes and reports about your patient's status, such as how they're feeling, their opinions on their treatment plan, and how they view their progress.
Relevant information: Describe any valuable, objective data such as therapy notes, documents, and test results to help keep your progress notes updated.
Interventions: Document the treatment modalities and interventions you applied during the session, such as relaxation techniques, cognitive restructuring, or mindfulness training.

Common terminology to use in progress notes

9. Treatment plan progress: With each progress note during each session, you should mention whether you and your patient are successful at achieving their treatment plan objectives.

10. Signature: You must always include your signature on your progress note documents to keep them compliant. You may also need to include your credentials.

As part of the overall therapy treatment for your client, you may also have an admission and discharge/dismissal note, which are important to keep in your records:

Admission note: Following the initial assessment session with your client, your admission progress note will include the presenting problem, the participants in the session, your observations, acknowledgment of informed consent and patient rights, and your recommendations.
Discharge/dismissal note: Following termination with your patient, corresponding with your final session, your discharge note will include a summary of the treatment provided, the level of progress achieved through the treatment plan, the reason for termination, and your recovery plan recommendations.

Common Terminology and Interventions to Reference

When documenting progress notes, it can be helpful to refer to common terminology and different interventions you can use to keep your notes professional and objective.

Some examples of common terminology used in progress notes to describe a patient's appearance and health include:

Affect, Mood, or Disposition: Depressed, dejected, lighthearted, disheartened, carefree, listless
Attitude: Disagreeable, apathetic, inert, quarrelsome, absence of effect
Behavior: Lethargic, spontaneous, immediate, over-cautious, sluggish

You may also include descriptions of a patient's cognition, orientation, or work habits from their direct quotes or your observations.

Here's a list of frequently used interventions you can reference to help you and other practitioners understand different treatments a patient might be undergoing with other specialists:

Behavior reinforcement
Collaborative problem-solving
Anger management
Communication skills development
Cognitive restructuring
Mindfulness
Progress or objective review
Coping strategies development
Stress management
Problem-solving skills development
Eye movement desensitization and reprocessing
Identifying triggers

Since you need to update your progress notes after each session with every client, here are some tips to keep in mind that can help boost efficiency in your note-writing process:

Read your progress notes before meeting with your patient to refresh your memory and know what to discuss.
Ensure your notes always mention the time and date of entry, the duration of your sessions, and your signature.
Refer to your previous progress note entries for continuity.
Document your notes as soon as possible after each session so you don't forget any important details.
Avoid using acronyms, abbreviations, and jargon in your notes, because it can be difficult for you and other practitioners to understand later.
If you make a mistake, cross it out and continue. Don't tamper with your entries.
Write down all relevant information or details about your sessions you think can be useful for developing or adjusting your treatment plan. Remember, if you don't write it down, it didn't happen.
Keep in mind, your progress notes contain confidential information and must always be kept in a secure location and only accessed by you, your patient, or other authorized behavioral health staff.

Why You Should Use EHR Software for Progress Notes

Depending on how many patients you see and how frequently, you can end up spending several hours every day writing your progress notes . Not to mention, hand-written, paper progress notes can present many issues, such as getting lost or damaged. Paper progress notes will also take you much longer to complete than electronic notes, such as those within electronic health record (EHR) software .

Research shows that clinical documentation contributes heavily to staff burnout because it takes significant time that therapists and other mental health professionals could instead spend with patients. One study found that clinicians welcome a serious redesign of documentation processes to restore autonomy, eliminate the number of actions that do not add value and return time to staff for more essential care activities.

By introducing EHR software, you can lift the burden of documentation with these benefits:

Making your notes legible, easy and quick to read
Reducing documentation errors or missing information
Preventing lost revenue due to under-coded notes or claims being rejected
Reducing time spent on documentation and record-keeping
Using client progress note samples and other templates for various types of therapy
Increasing your peace of mind that your notes will pass regulations
Simplifying and minimizing the expense and turnaround time of transcribing clinical dictation

ICANotes Can Help You Write Your Progress Notes

As a mental health therapist or practitioner, improving your note-writing processes can help you create more effective, useful, and legible progress notes that make it easier to communicate with other professionals about your patients. With ICANotes, you can access several charting and note templates for quick, comprehensive documentation.

Our behavioral health EHR contains many specialized features designed to help you reduce your documentation time, comply with regulatory requirements, get paid faster, and spend more time with your clients. To learn more about our service and features, contact us today or start your free trial to see how our software can enhance your progress notes.

Start Your Free Trial Today

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How to Write a Nursing Progress Note: Tips and Infographics from Nursing Practitioners

How to Write a Nursing Progress Note: Tips and Rules from Experts [Infographics]

Medical professionals know the importance of notes nurses leave to track down the path of a patient. Before students even begin to practice writing these notes, they learn various types of medical documentation, what they need to include in them, and why they need to write them. Let’s do this all together to get a clear understanding of what we are to prepare.

🤔 What Is a Nursing Progress Note?

A nursing progress note is a legal record of all events that happen with the patient, including the time and date of entry, the welfare of the patient, medicine and procedures they go through. It is crucial to include all the details in the progressive note to compare the status of the patient on the path of recovery to the date of entry and track the progress of the patient. This helps to improve the quality of care and follow-up on all actions taken.

📝 What to include in a Nursing Progress Note: Cheat Sheet

Writology.com has gathered experts in various fields to help you with your studying and career course. We bring in professional researchers, writers with practical nursing experience, and certified editors to help people and provide them with valuable tips to gain success.

✅ Details that are important to include in a competent nursing progress note

Date and time. Every update on the progress note has to include the date and time as it keeps it chronological and monitors any results in the patient’s progress.

Patient’s name. Definitely, it is already mentioned somewhere in the note, but double-check and make sure it is there. Moreover, some healthcare facilities require a patient’s name to be written near every update you write in the medical documentation.

Doctor/Nurse’s Name. It is obligatory to include this information to track down the changes applied to the patient’s healthcare plan and why these changes were applied.

Description of the patient. This information might not seem as relevant as other pieces of data, but as a nurse practitioner, you know that doctors or nurses might change and substitute each other. Small facts that provide a general description of the patient can help a therapist distinguish the right person from others and ensure that no one is pretending to be someone else.

Subjective data. These are details that patients themselves provide to doctors. It includes:

Reason for the visit
Symptoms a patient might experience
Level of pain
Concerns and thoughts a patient might have

Objective data. This data appears as an opponent to the subjective data you get from the patient. Objective data includes the following points:

Signs and symptoms you might observe (pain the patient feels or probably fakes it, vertigo you can note from the way a patient acts)
Vital signs
Initial health assessment
Laboratory results, tests, bloodwork

Assessment. A nurse may conduct and include either a targeted or head-to-toe assessment. The decision regarding any of the mentioned examination types depends on the purpose of the visit and the patient’s condition.

Diagnosis and care plan. Depending on your role as a healthcare professional, you will need to provide the initial diagnosis and possible treatment plan. It might be reviewed or improved later during the recovery process and based on the response of the patient to the prepared care plan.

Patient’s response to care. These details are vital for following the reactions of a patient to various medications and procedures a patient goes through. Some medical institutions require adding information on changes in patients’ behavior, welfare and emotional state as it might directly impact patients’ recovery.

Interventions. Any updates, procedures, and tests have to be included in the note to follow up on the progress of a patient. It is also a good idea to include any education you provide for the patient in their situation and what they need to do to improve their health.

Evaluation. The evaluation part has to include information about the response of a patient to any interventions. The amount of information depends on the assessment of the intervention you are currently providing. It can contain one or several sentences about whether the drug works and how the patient feels.

Details that are important to include in a competent nursing progress note

❌ What Information Do You Need to Avoid In a Progress Note?

Symptoms Without Any Intervention. Whenever you note any symptoms or complaints of a patient, include how you handled the situation, and what medication was used.

Speculations. With your experience and knowledge, you might know what symptoms a person might have, but you need to be extra attentive and hear what is going on with a particular individual. It is crucial not to speculate but to note and document not only what a patient says or feels but what you see and how they react.

Non-precise terminology. A note has to create a vision in the mind of the next person on shift. Professional terminology and commentary are critical in this type of medical documentation.

Incomplete care charting. Do not include any intervention and care unless it is done because any day might bring surprises, even when you plan it to the details.

Personal details of patients’ visitors. It is relevant to include general information about the visitors, but it is incompetent to bring information about how visitor treats you or a patient.

🖊️ So How to Write a Nursing Progress Note?

Note: a SOAPIE method is a common guide for nursing practitioners to fill out a nursing progress note. SOAPIE stands for subjective, objective, analysis, plan, implementation, and evaluation parts. This way, it is easy to remember all the details that are relevant to include. In case you need assistance or guidance via this process, our experts are ready to assist you since we provide professional nursing essay writing services .

Collect all the relevant information.

Initial data you get from a patient is considered subjective as it shows the welfare and perspective from their point of view and knowledge. This part includes the pain a person feels, the level of pain, and the reason for their appointment. You might also note any concerns a patient has. In case a patient comes with a friend or family member, you are more than welcome to ask if they have noticed anything in the welfare of the individual or how long the situation lasts. Remember to be attentive when listening to every person, and show sympathy.

Note the objective information you get during the assessment.

Objective information you will get from the vitals and tests of a patient usually supports the subjective information a person includes.

Once you have all the information you need, please write it down and consult with a doctor or primary care physician and determine an appropriate diagnosis for a condition of an individual under assessment.

After establishing the primary nursing diagnosis, developing a medical action care plan is necessary. This plan might follow a protocol for the disease, an estimation of medications needed and a request for them from the providers. You can also include details about the emotional support the person needs, and all care should be built with the patient at the center and take into account the diagnosis.

Implementation.

Once you have a plan, you need to take action. It is obvious that something might not go exactly as planned, and it happens. No need to worry in such cases. All you need to do, just write down all the actions performed, including those that you attempted to perform.

Evaluation.

You can evaluate the outcomes only after the interventions are performed. Evaluation might require a patient reassessment to review an individual’s well-being and make proper conclusions. You can simply go through the last points until it improves the patient’s health.

🎖 4 Best Tips on How to Write a Nursing Progress Note

Always sign the notes you leave with your last name and initials and leave a signature.

This information is required to identify who made the interventions and applied the changes.

Use the active voice.

Why is the passive voice not good? Hmm, nobody said that. The passive voice is formal. However , it might confuse the next person on shift, especially if it is a long shift, which we all know might happen due to workload. Moreover, when you write notes in a passive voice, some important details might be missed, and we don’t need such omissions to ensure a patient gets relevant health care.

Include only appropriate information.

A professional nursing progress note demonstrates a perfect harmony of brevity and detail. You need to remember that too much information might make the note impossible to scan in emergency situations. How to include only relevant information? Use the SOAPIE method and remember our little tips regarding professional notes.

Use professional terminology and abbreviations.

The main tip on how to write a nursing progress note you need to remember is to stay professional and use correct terminology and common abbreviation. The next nurse or doctor needs to understand every detail you left in the note.

Writology.com is right here to improve your experience as a student, help you learn, and ease your life. Our team of experts with practical nursing experience provides custom nursing essay writing assistance for nurses worldwide. Do not hesitate to contact us! We are here for you 24/7 all year.

🔗 References

5 Nursing Narrative Note Examples| Nursing Process

How to Write Nursing Progress Notes — With Examples

12 Tips For Writing Progress Notes

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Ultimate Guide to Progress Notes | Carepatron

how to write lab results in progress note

By Jamie Frew on May 06, 2024.

Fact Checked by Ericka Pingol.

Progress notes are essential tools for healthcare professionals, serving as a critical component of clinical documentation. Alongside other records, progress notes help compile a comprehensive dossier that captures a patient’s journey through the healthcare system.

This guide aims to provide insights into the effective management and utilization of progress notes to ensure accurate and efficient patient care.

Understanding progress notes in healthcare

Progress notes are essential to clinical documentation and crucial for tracking patient progress and managing healthcare effectively. These progress notes serve several vital functions: document a patient’s health history across multiple visits, which aids in ongoing assessment and treatment planning. They also facilitate communication between healthcare providers, ensuring cohesive and informed patient care, especially when transferring care between departments or facilities.

Additionally, progress notes play a critical role in legal protection, providing a detailed account of patient interactions, treatments, and decisions made by healthcare and other mental health professionals. This documentation can be indispensable in defending against legal claims or investigations.

Furthermore, progress notes are essential for the medical billing process, as they help create billing codes necessary for insurance claims and reimbursement. By mastering adequate progress note documentation, healthcare professionals can significantly enhance the quality of care, ensure legal security, and maintain financial stability within their practice.

Difference between progress notes and psychotherapy notes

Understanding the key differences between clinical documentation forms can be confusing, especially regarding Progress Notes and Psychotherapy Notes. Although both documents are records kept by healthcare providers, they serve entirely different purposes:

Progress notes and psychotherapy notes are essential tools in healthcare and mental health settings, respectively, though they serve different purposes and adhere to specific guidelines.

Progress notes are written by healthcare practitioners such as nurses, doctors, and therapists involved in a patient’s care. They include subjective notes, which capture the patient's reported symptoms and concerns; objective notes, which detail vital signs, physical examination findings, and treatments provided; and notes on the treatment plan and observable progress, documenting the patient’s response and any improvements. These notes facilitate communication among various healthcare providers and can be used in legal contexts or by insurers. Ensuring HIPAA compliance is crucial to protect patient information in these documents.

In contrast, psychotherapy notes are crafted by mental health professionals like psychologists and psychiatrists. These notes focus on the therapist's perspective, containing observations, opinions, interpretations, and hypotheses about the patient's mental health based on the current session. They often exclude detailed medical information and are generally kept confidential, accessed only under specific legal circumstances, despite also requiring strict adherence to HIPAA guidelines to ensure privacy.

Understanding these distinctions helps healthcare professionals maintain accuracy in their documentation and uphold the confidentiality and privacy of patient information.

When should you write progress notes?

Progress Notes should be written at specific times to balance patient engagement and the records' accuracy. Writing progress notes during a session is not advisable, as it can detract from the patient's appearance of care and give the impression that the practitioner is not fully attentive. Conversely, delaying the documentation can lead to forgotten details and a backlog of paperwork, which can be overwhelming and disruptive, especially at the end of a busy week.

The recommended practice is to write progress notes immediately after each patient session or at the end of the day. This approach ensures that details are recorded accurately while still fresh, helps maintain an efficient workflow, and avoids the accumulation of unwritten notes, which can significantly burden mental health professionals.

Tips for writing good progress notes

Several strategies are essential to produce highly effective progress notes. First, maintain objectivity within the notes. Although some subjectivity is necessary to reflect the practitioner’s professional opinions on the patient’s presentation, evidence should always support these. Avoid using language that carries negative connotations to keep the tone of mental health progress notes neutral and professional.

Progress notes should be thorough yet concise. The challenge lies in including necessary details without overwhelming the document. Each sentence must add valuable information. Avoid vague or repetitive language, and keep Progress notes to a maximum of two pages to ensure they are easily digestible by other providers or third parties who may review them.

Legibility is also critical, particularly for handwritten therapy notes. Poor handwriting can lead to miscommunication and potentially affect treatment outcomes. If handwriting is not clear, transitioning to electronic note-taking methods is advisable. This not only improves legibility but also enhances the accessibility of the notes.

Finally, the accessibility of progress notes is crucial due to their frequent use among various healthcare providers. Implementing electronic health record (EHR) systems can significantly improve accessibility, allowing authorized users to access needed information efficiently and securely. This helps maintain continuous and coordinated care across different healthcare settings.

Things to avoid when writing progress notes

Effective progress notes require meticulous attention to avoid common errors compromising patient care. Each note should be correctly dated and signed, ensuring validity in legal and insurance contexts. When making corrections, it’s essential to strike through the error, date it, and initial it, maintaining the integrity of the documentation.

Medical jargon should be avoided to ensure clarity for non-medical readers like insurance adjusters or legal representatives. Instead, use clear and universally understandable language. Avoid assumptions and vague statements; all subjective opinions should be well-supported by evidence to keep the notes objective.

Lastly, legibility is crucial for effective communication. For those with poor handwriting, using an electronic system to keep notes can prevent misinterpretations. Documenting every encounter, including telehealth sessions, is essential; undocumented encounters can lead to gaps in a patient’s medical history.

HIPAA compliance for secure progress notes

Maintaining patient privacy is paramount in healthcare. The HIPAA mandates how protected health information (PHI) is handled within progress notes. This includes personal details, medical history, and treatment specifics.

Here are some key points to remember:

Sharing PHI requires explicit patient authorization, except in limited cases like potential harm to the patient or public.
Patients have the right to access their progress notes.
Progress notes should be professional, relevant, and objective to avoid confidentiality breaches.
HIPAA requires training staff on compliance and strict action against breaches (fines, license loss, jail time). Breaches can also damage reputation and trust.

Secure storage of progress notes

Electronic storage is highly recommended for enhanced security. Here's why:

Encryption and remote storage

Encryption is the process of converting data into a coded format that can only be decrypted with a specific key or password, ensuring that data remains secure even if intercepted. Remote storage refers to storing data on servers in secure facilities away from the primary use site, minimizing risks like theft, loss, or damage.

Electronic protected health information (EPHI)

EPHI refers to any protected health information that is created, stored, transmitted, or received in electronic form. The HIPAA Security Rule mandates specific safeguards to protect EPHI and ensure its confidentiality, integrity, and availability. Here are more details about the safeguards:

Administrative safeguards: Policies and procedures designed to manage the conduct of the workforce in relation to the protection of that information. This includes everything from hiring practices to how access to sensitive data is granted and managed.
Technical safeguards: Mechanisms built into IT systems that protect data and control access. These include using strong encryption methods for data at rest and in transit, employing access control to ensure only authorized users can access data, and implementing secure communication protocols.
Physical safeguards: Measures to protect the physical systems and the facilities where information systems are housed. This includes secure access to buildings, controlled access to IT areas, and protection against environmental hazards like floods and fires.

No system is foolproof, but using electronic storage with these safeguards significantly reduces the risk of unwanted access to your data.

Moving forward with compliance

Understanding HIPAA regulations for clinical documentation can be complex but essential. While we've provided a basic overview, further research is highly recommended. Here are valuable resources:

Guide to privacy and security of electronic health information : This is a basic overview of HIPAA guidelines. The website has links to training games and risk assessment tools.
State attorneys general : A more comprehensive overview of HIPAA and HITECH.
CMS HIPAA basics for providers : Details of the providers' role in adhering to HIPAA compliance, with additional information on the breach notification rules and possible consequences of non-compliance.

By prioritizing secure storage and understanding compliance regulations, you can ensure patient privacy and trust in your healthcare practice.

Different progress note templates

The importance of effective progress notes has led to the development of tools like progress note templates to assist healthcare practitioners. These templates are handy for those new to the profession, as they provide a structured format to ensure all necessary information is included in therapy progress notes.

By far, the most widely used of these templates is SOAP. SOAP notes separate the information into four categories: Subjective, Objective, Assessment, and Plan. SOAP notes are prevalent across a wide range of healthcare professions; they allow practitioners to organize their patient records well without compromising the authenticity of their notes.

Subjective (S) : This section focuses on the client’s feelings and experience of their symptoms. This may include when the symptoms started, whether they have improved or worsened, and how they impact the patient’s everyday life. Often, practitioners will use quotes as primary evidence for support.
Objective (O) : This section includes relevant factual data to support the symptoms reported by the client. Examples of evidence may include medical records, x-rays, examinations, test results, laboratory data, and vital signs.
Assessment (A) : This section combines subjective and objective observations, including the client's progress and current diagnosis, improvements noted, and specific tasks that may benefit the client.
Plan (P) : Includes the direct course of action for the client's progress, focusing on any adjustments required for their treatment plan. This section should introduce specific goals for the client to achieve, as well as upcoming appointments and/or referrals.

Mental health practitioners typically use BIRP notes to document their sessions with clients. They are similar to SOAP notes in that they are separated into four sections: Behavior, Intervention, Response, and Plan.

Behavior (B) : This section includes objective data and subjective information regarding the patient. Frequently using quotes, the symptoms that the patient is experiencing should be recorded, in addition to the practitioner’s objective observations of the patient. This may include comments on their behavior, appearance, and mood.
Intervention (I) : The intervention section focuses on the therapeutic interventions and concisely summarizes the session with the client, emphasizing current goals and objectives. The practitioner should mention their strategies during the session and how they relate to the patient’s diagnosis and treatment.
Response (R) : This part of the progress note relates to information regarding how the patient responded to the practitioner’s intervention and treatment strategies.
Plan (P) : The note concludes with comments on the patient’s plan, in particular, the date and time of the next session and the focus of that session.

The DAP note is similar to the SOAP note, except it is divided into three sections instead of four. Although the information included within a DAP note needs to be just as thorough as that of a SOAP or BIRP note, it is often considered a more straightforward format.

Data (D) : This section can be considered a combination of subjective and objective information and covers all of the vital information discussed during the session. This includes (but is not limited to) the patient’s symptoms, condition, behavior, affect, and responses to treatment.
Assessment (A) : The practitioner takes the information provided in the data section, analyzes it, and reaches a conclusion. This section may include a professional opinion of how the client responds to treatment, whether or not they have made progress/achieved goals, and a probable diagnosis.
Plan (P) : The final section combines the information provided to create a plan for the patient’s future treatment. This may involve specific details regarding the next session, the patient’s target treatment goals, and any modifications to the current intervention.

Examples of excellent progress notes

We’ve covered all the bases for writing and storing progress notes correctly. At the end of the day, practice is the only way to become an expert, no matter how much information you read about Progress notes. We have compiled a list of example progress notes from various healthcare professions that should indicate the type of information and layout required for a good note.

1. Therapy progress note

“I feel like I am a failure at work. I work as hard as possible but have always been overlooked, and my self-confidence plummets. It’s affecting how I am at home, and I’m beginning to feel miserable.”

Thomas had a flat expression and remained slumped in his chair throughout the session. He indicates feelings of low self-esteem that are beginning to impair his day-to-day life.

This is Thomas’ first session, and he needs to find ways to communicate his emotions to his work while realizing his self-worth. Failure to do so will likely result in increased depressive feelings for Thomas.

Thomas will attend further sessions, and we have conducted a plan to work on his perception of self and ways to problem-solve at work. If symptoms do not improve within the next two weeks, a therapist or psychologist will discuss additional treatment and reevaluation.

2. Psychology progress note

Luke reports he constantly thinks about "what-ifs," which engages him for hours and makes it hard for him to stop. He expresses that this significantly impacts his daily functioning, affecting his ability to concentrate on university work and job responsibilities. Luke also notes a decreased appetite, stating, “I don’t eat much anymore, as I just don’t get hungry.” Objectively, Luke shows increased signs of anxiety, including racing thoughts and a lack of concentration, with consistently higher-than-average blood pressure readings during assessments.

Luke's symptoms have worsened, indicating that the current treatment approach is not effective. His increased anxiety symptoms, particularly his prolonged ruminations and decreased appetite, highlight the need for a revised treatment plan with more focused interventions.

In today's session, we worked with Luke to develop a meal plan requiring him to check off meals eaten regularly to ensure proper nutrition. We also introduced new techniques for managing anxiety, including breath control exercises, mood regulation strategies, and rumination avoidance techniques. Luke is instructed to follow these strategies closely over the next two weeks. We will evaluate his progress in the next session and consider further or alternative treatment options if there is no improvement.

3. Physical therapy progress note

Jane displayed a positive attitude and willingness to engage in all prescribed physical therapy exercises. She reported experiencing mild to moderate pain in her left knee, particularly during flexion and extension movements. Throughout the session, she walked slightly limp and relied on her walking aid, a cane.

Intervention

During the session, we conducted gentle range-of-motion exercises to increase knee flexibility. Strength training exercises focused on the quadriceps and hamstrings to build muscle support around the knee. After completing the exercises, we applied a cold pack to reduce swelling and manage pain. Additionally, we guided the proper use of the cane to ensure Jane's safety and support while walking.

Jane tolerated the exercises well but reported increased pain during the more intense phases of the strength training. She could complete most of the exercises with encouragement and occasional breaks. The cold pack application visibly reduced swelling, and Jane noted decreased pain following its use. She also demonstrated improved technique in using her cane by the end of the session.

For the next session, we will continue with the current set of exercises but will adjust the intensity based on Jane's pain feedback. We plan to introduce low-impact aerobic activity to enhance overall knee function and support weight management, which is crucial for reducing stress on the knee. We will also continue to focus on proper walking aid usage to improve mobility and prevent further injury.

Progress notes in the digital age

Healthcare documentation is evolving alongside technology. As digital tools become more sophisticated, their integration into healthcare offers significant advantages for patients and practitioners. Let's explore some key technologies impacting progress notes.

Electronic health records (EHR)

EHR systems are a cornerstone of modern healthcare IT. They enable practitioners to electronically create and store progress notes using secure, cloud-based technology. Here's what makes them valuable:

Enhanced security: Controlled access, two-factor authentication, and encryption ensure data security.
HIPAA compliance: EHR systems should be HIPAA-compliant, with robust protocols for data breaches. Evaluate security measures and breach response plans when choosing an EHR system.
Improved access: Authorized users can access notes 24/7 from any device, facilitating collaboration and care coordination.
Reduced errors: Digital text editors minimize typos and improve legibility compared to handwritten notes.

Electronic vs. paper progress notes

While EHR adoption is increasing, some practitioners remain hesitant. Let's compare the pros and cons of each approach:

Electronic notes

Electronic notes represent a modern approach to documenting patient care, utilizing technology to streamline and secure medical records management. This method is increasingly prevalent in healthcare settings due to its efficiency and accessibility.

Here are some advantages of using electronic notes in healthcare:

Time-saving: Electronic notes streamline various processes such as entering, retrieving, and managing data, allowing healthcare providers to access patient information quickly and efficiently.
Reduced errors: Using templates and automatic error-checking functions can minimize common mistakes like illegible handwriting and incorrect data entry.
Improved accessibility: Authorized personnel from multiple locations can access electronic notes remotely, facilitating better collaboration among healthcare providers.
Enhanced security: With the implementation of encryption and secure access protocols, electronic data is less susceptible to unauthorized access than physical notes.

While providing many benefits, electronic notes also have some cons, like:

Potential online security risks: Despite strong security measures, electronic systems can be vulnerable to cyber-attacks, which may lead to data breaches and unauthorized access to sensitive information.
Learning curve: Some practitioners, particularly those accustomed to traditional methods, may find it challenging to adapt to electronic systems. Training and adaptation can require significant time and resources.

Handwritten notes

Handwritten notes have been the traditional method of recording patient information, favored by many practitioners for their simplicity and direct approach. Despite their longstanding use, handwritten notes have significant limitations that impede efficient healthcare delivery.

Let's take a look at some of the pros of handwritten notes:

Familiarity: Many practitioners are accustomed to handwritten notes and may find them simpler to use without the need for technology, making this method preferable, especially in settings lacking robust IT infrastructure.
Personalization: Handwritten notes have a personal touch, allowing for individualized notes that reflect the specific needs of each patient.

Here are some common disadvantages associated with handwritten note

Time-consuming: Handwriting notes is generally slower than typing, particularly for longer documents. This can lead to reduced efficiency in patient care and documentation.
Prone to errors: Handwritten notes can be affected by individual handwriting variability, leading to errors in interpretation that are less likely with typed text.
Messy and illegible: Poor handwriting can lead to notes that are difficult to read, which can impede medical care and lead to mistakes.
Vulnerable to loss or damage: Paper notes are susceptible to physical damage from fire, water, or simple wear and tear. They can also be lost, which poses a significant risk in maintaining comprehensive medical records.
Hinders communication and record-keeping: Sharing handwritten notes among multiple practitioners can be cumbersome, leading to delays and inefficiencies. This method also makes creating backups and securely storing extensive records difficult.

The clear choice

Electronic notes offer numerous advantages that can be harnessed to improve efficiency, patient care, and overall practice management. The time saved by EHRs allows practitioners to dedicate more time to patient interaction and deliver higher-quality care.

What should you look for in progress note software?

When choosing progress note software, there are several key factors to consider that will ensure the software meets the needs of your healthcare practice effectively:

Customization : Look for software with customizable features for various healthcare professions, such as nursing, psychology, physiotherapy, and occupational therapy. This ensures the templates and tools are relevant and valuable.
Integration : The software should seamlessly integrate with existing systems like EHR or EMR to enhance productivity and communication. This allows for efficient data sharing and transfer across different platforms.
Billing integration : Since clinical documentation often supports billing, opt for software integrating documentation with billing to streamline reimbursements.
Voice-to-text capability : Dictation tools can significantly reduce the time spent writing notes by allowing practitioners to dictate their observations directly into the system.
HIPAA compliance : Ensure the progress note software complies with HIPAA regulations to protect patient information and avoid potential legal and financial penalties. Check the software’s security protocols to assess its compliance standards .

These features will help you choose a progress note software that enhances the efficiency and compliance of your healthcare practice.

Final thoughts

We’ve thoroughly explored everything essential about progress notes, including their importance and how to refine them using available tools. While preferences vary among practitioners, we stress the value of EHR systems and related software to enhance healthcare efficiency.

Despite your current methods, we encourage you to explore various progress note systems. Experimenting with these technologies could significantly increase operational efficiency and allow more time and resources dedicated to direct patient care. You never know the full potential of what you’re missing until you try it!

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01.06 How to Write A Nursing Progress Note

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Assessments
Care & Treatments
Chronological report
Includes responses, changes and issues
Legal evidence
Reimbursement
Quality assurance
Physical assessment
Patient interview
NANDA nursing diagnosis
Prioritize care
Set goals/outcomes
Interventions
Determine outcomes
Determine effectiveness of interventions
Make changes as needed
Patient condition
Diagnostic procedures
Other interventions
Patient response to interventions
Care & teaching provided
Complaints/other issues during care
Separate notes for each team member
Most popular
What the patient says
Why is the patient here?
Onset of symptoms
Location of symptoms
Duration of symptoms
Character of symptoms
What relieves or makes it worse?
Does it stay in one place or move?
Is it worse at a certain time of day?
Scale of 1-10
Things we observe
Uses nursing diagnosis
Nursing diagnosis
Care/treatment provided
Did the intervention work?
Highlights specific problem, condition changes, concerns or events
Be consistent
Never chart in advance
Always notate date and time written
Familiar to other medical personnel
Approved by agency/facility
Avoid opinion/personal feelings
Note all communication
Sign all notes with credentials
Write legibly
Use black ink
No white out
Sign/initial error
Date and time with initials

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Nursing Documentation Principles

Today we’re going to be talking about how to write a nursing progress note.

In this lesson, we will cover the types of progress notes you can write, what information actually goes into a progress note, and what you absolutely must know before you begin writing one.

Let’s start by addressing what a progress note is. Nursing progress notes document our patient’s medical status. We document any assessments, care and treatments we’ve performed on our shift, and the patient’s progress and response to those actions. The goal of the progress note is to write a chronological narrative of the shift including any issues you may have come across. For instance, you can write a note after you complete your initial assessment. It may look a little something like this: (date/time: Physical assessment completed. VS WNL. Pt A&Ox3, no complaints of pain at this time. RN signature). If there’s anything abnormal about your assessment, it would go here as well along with any interventions you may have had. Remember that nursing progress notes are legal documents and can be used in court proceedings, for insurance reimbursement and for quality assurance purposes.

The nursing process is something that will never go away. It shapes the way we work as nurses! With that said, it’s important to show you how it affects the way we write our progress notes as well. So our assessment is anything we found in the physical assessment or in the patient interview. You’ll want to include that information in your note, particularly for those findings that aren’t normal. NANDA diagnoses are used dependent on your facility policy, but you may want to use it to determine what your central focus is for your patient. It will help shape your plan of care. As I’m mentioning plan, this is where we are prioritizing our care. This is why I say you can use the NANDA diagnosis. In the process of prioritizing, you should be setting goals for your patient to achieve on the short term. Maybe you want them to achieve something before the end of your shift, or before discharge. Interventions are the implement stage of the process. These are those treatments and any other care we are providing during the shift. Finally, we have the evaluate stage. This is where we are looking for the response to interventions and making changes to the plan as needed. Why did I bring this up? We all know ADPIE at this point but what you may not know is you can always refer back to it if you get stuck on what to write in your notes.

What do we put in a progress note? Remember, we are creating a narrative description of what happened with the patient during the shift. So we want to include the patient’s condition and any abnormal lab values or diagnostic results. Any tests that the patient had completed or ordered should also be included even if we don’t have the results back. Medications and treatments, as well as the patient’s response to them are very important to include. This includes any patient concerns, complaints or other issues as well as the care or any teaching we have provided during the course of the shift. We want to know if they tolerated the treatment or if a change has been made or is warranted. Were there any new med orders made? We also talk about any follow up care or consults that may be required. When you hear it in a list like this it sounds like a lot. But think about what you’re expected to do on your shift as a nurse. The most important take-away here is that you want to document the things that happened, because if you don’t, it didn’t.

There’s a lot of different ways to write a progress note, however, we will discuss the ones you may see most frequently. These are the SOAP note, the PIE note, and the DAR note. Let’s explore each of these individually.

SOAP notes are the most popular progress note for nurses. They fall into the category of problem oriented notes, which means we are focused on the reason for seeing the patient. It lays out exactly what we need to include. Subjective information is what comes from the patient. We take this information in the History & Physical most often and it includes not only why they are here with us, but also the details of their symptoms. Objective information is what we observe, usually from the physical assessment we perform. Bear in mind there can be times where S and O don’t necessarily add up, but make note of it all anyway. Then we have the assessment and the plan. Again, we take that from the nursing process. Find the problem and make a plan to fix it. So let’s say we have a patient who just had abdominal surgery 2 days ago. The SOAP note may look something like this: S – Pt reports pain and itching around surgical site. Pt states the pain is 4/10 and throbbing. O – Pt A&Ox3, calm and cooperative. VS WNL. No edema to extremities. Lungs clear. OOB to chair with assistance. Positive bowel sounds in all 4 quadrants. Redness and swelling around surgical site. Tenderness noted in LUQ. No drainage or bleeding present. Dressing CDI. Pain medication given per order for mild to moderate pain. Call light in reach. A – Pt pain level decreased to 2/10 after pain medication. Pt has some SOB after ambulation to chair and c/o mild fatigue. P – Will continue to assist with activity as tolerated. Continue pain medications, skin care and dressing changes as ordered. Assess surgical site throughout shift. Report any other issues to physician.

PIE notes are another problem oriented note, but these rely on the use of the nursing diagnosis to identify and document the problem, discuss the care or treatment provided, and then whether or not the intervention actually worked. PIE notes are a little more clear cut and to the point, but don’t allow for as much detail as SOAP notes. Let’s use the same patient we just discussed. The PIE note may look like this: P – Acute pain r/t surgery as evidenced by reports of pain 4/10. I – Administered pain medication as ordered for mild to moderate pain. Assistance provided for OOB activity. Call light placed in reach. E – Pain decreased to 2/10. Pt uses call light when in need of assistance. We said the same thing as we did in the SOAP note, just more concise and we focused on a central issue, in this case, the patient’s pain. If there are other issues, you can write on those as well.

DAR notes are in a different category than SOAP and PIE notes. These notes are called focus notes, which highlight a specific problem, condition changes, concerns or events. When you think of it that way, it’s easy to determine what each piece is for, but I’ll explain anyway. Our data comes from the assessment findings. So this is likely both subjective and objective information if you think of it in terms of SOAP notes. Action and response are exactly that. What did we do to address the problem we’ve identified, and did it work. Let’s revisit our post op patient again. The DAR note may be this: D – Pt is 2 days post op abdominal surgery. Pt c/o pain 4/10 around surgical site. Some redness, swelling and tenderness noted at the site. A – Tylenol 325mg 2 tabs PO administered as ordered for mild to moderate pain. R – Pt reports pain decreased to 2/10 after medication administration.

So we’ve arrived at the rules for writing progress notes. Remember, we said earlier that progress notes are a legal document. If you are ever called to testify in court, your notes can be used as evidence so you want to be sure that you are consistent, concise and timely with your notes. Never write notes in advance. Anything can happen and more importantly, if you’re writing ahead of time, do you really have true knowledge of the situation? We love to use short-hand in the medical field. It’s okay to do this, just be mindful that the abbreviations you use are standard and approved before doing so. Make sure that what you are using is familiar to everyone reading. No one wants to have to track you down to clarify what you meant. Include any and all communication you’ve had regarding your patient and ensure that you use quotations so it is clear that what you are writing was a statement made by the person you are referring to. This includes family members, visitors, and medical personnel. This is important, because once it’s written down, it can’t be denied or changed. Above all else, you earned your credentials. You worked hard for them. So make sure you are using them when you sign off on your notes. It’s a standard you will get used to.

A final note for those who still create hand-written notes. Make sure you write legibly in black ink only. This is a legal requirement, I’ve always been told. Also correcting errors is a really big thing for legal reasons. We all make mistakes and it’s okay to as long as you find it and correct it. When you do make an error, know that white out is not permitted. You should put one line through the error, and initial with date and time.

Let’s talk some key points. Remember progress notes are legal documents. They can be used in court or for insurance to pay your facility. Be mindful of what you write. If you ever get stuck on what to include in your progress notes, it’s okay. You can always come back home to the nursing process! A goal in writing progress notes is to stay objective! It is not the place to air your grievances and should stay judgment free. Document ONLY the facts! Most important, always remember, If it’s not documented, it didn’t happen. Make sure you hit everything you want the reader to know.

That’s all! We love you guys! Go out and be your best self today! And as always, Happy Nursing!

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Documentation.

Documentation can be hard! This course will take you through the daily charting and documentation that is necessary for your patients. In this course, you will also understand documenting phone calls, the legalities of charting, and how the electronic medical record (EMR) works.

0 – Documentation Course Introduction

1 – documentation basics for the new nurse, 2 – legal responsibilities.

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Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern

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Miao Wei, Efrain Salgado, Christine E Girard, Jonathan D Santoro, Natasha Lepore, Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern, Postgraduate Medical Journal , Volume 99, Issue 1171, May 2023, Pages 492–497, https://doi.org/10.1136/postgradmedj-2022-141834

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A physician’s progress note is an essential piece of documentation regarding key events and the daily status of patients during their hospital stay. It serves not only as a communication tool between care team members, but also chronicles clinical status and pertinent updates to their medical care. Despite the importance of these documents, little literature exists on how to help residents to improve the quality of their daily progress notes. A narrative literature review of English language literature was performed and summated to provide recommendations on how to write an inpatient progress note more accurately and efficiently. In addition, the authors will also introduce a method to build a personal template with the goal of extracting relevant data automatically to reduce clicks for an inpatient progress note in the electronic medical record system.

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5 Nursing Narrative Note Examples + How to Write

One of the most important lessons nursing students learn is the importance of documentation. Whether you are a nursing student or a seasoned nurse, knowing how to create accurate nurses' notes is vital. Narrative nurses' notes are one of the most popular forms of nursing documentation. Perhaps you are wondering how to write a nursing narrative note? In this article, I will share 5 nursing narrative note examples + how to write them and discuss the importance of accurate charting.

What Is A Nursing Narrative Note?

Featured online msn programs, what is the purpose of writing a nursing narrative note, what is the difference between a nursing narrative note and a nursing progress note, 3 advantages of nursing narrative notes, 3 disadvantages of nursing narrative notes, what elements should be included in a nursing narrative note, • date and time:, • the patient’s name:, • subjective data:, • objective data:, • assessment:, • interventions:, • evaluation:, what elements should not be included in a nursing narrative note, 1. symptoms without intervention:, 2. speculations:, 3. non-descriptive or non-precise terminology:, 4. premature charting:, 5. personal information about the patient’s family or loved ones:, how to write a nursing narrative note, 1. stay on point and be specific, 2. state the facts, 3. note presentation, 4. note objective data, 5. record subjective data, 6. make notes regarding your assessment, 7. record any medication you administer or treatment you perform, 8. did you have to include interdisciplinary team members, 9. don’t forget to sign each entry of your note with your name and credentials, what are some excellent examples of nursing narrative notes, example #1: head-to-toe admission assessment narrative note for patient admitted with recent cerebrovascular accident (cva), example #2: assessment of nursing home resident, example #3: nursing narrative note example for patient recently admitted and found on hospital floor, example #4: patient with complaints of left knee pain, example #5: patient complaint of nausea, prn medication administered, bonus 6 expert tips for writing an excellent nursing narrative note, 1. document nursing actions immediately., 2. keep documentation descriptive., 3. be objective., 4. add new information anytime it is necessary., 5. convey enough information to get your point across., 6. make sure your handwriting is legible., my final thoughts, frequently asked questions answered by our expert, 1. who can write a nursing narrative note, 2. when to write a nursing narrative note, 3. can i use abbreviations in a nursing narrative note, 4. what tense do you write a nursing narrative note, 5. are nursing narrative notes handwritten or printed, 6. how to sign off a nursing narrative note, 7. what happens if i forget to write a narrative note in the time it should have been written, 8. should i write about a patient crying in my nursing narrative note, 9. how to note pulses on a nursing narrative note, 10. how to describe lab results in a nursing narrative note, 11. can a nursing student write a nursing narrative note, 12. what are the common mistakes nurses make when writing narrative notes.

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Guidelines and Tips to Write Good Progress Notes

Progress notes are among the most important reports that a medical transcription company helps physicians document in the electronic health record (EHR). These brief notes, also called SOAP (Subjective, Objective, Assessment, Plan) notes, document various aspects of the patient’s treatment and highlight important issues or concerns relating to care.

Clinicians need to know how to ensure effective and efficient EHR documentation. Good progress notes tell the patient’s story and prioritize patient care and safety. According to a new study published in the Association of American Medical Colleges’ MedEdPortal, sufficient EHR documentation training can enhance a resident’s knowledge of writing progress notes, which in turn, could lessen the risk of clinician burnout in the future. Researchers at the University of Wisconsin School of Medicine and Public Health (UWSMPH) found that EHR training workshops helped residents grasp the details and intricacies of EHR documentation (www.ehrintelligence.com).

Aims and Functions of Progress Notes

Progress notes provide information relating to the following:

Medical decision-making : Progress notes allow clinicians to record their work with the patient. This includes the clinician’s ongoing efforts to assess and manage the patient’s symptoms.
Patient-provider communication : A progress note covers the entire interaction between the patient and health professionals, including physicians, nurses, pharmacists, dietitians, and physiotherapists
Critical thinking : Patient notes reflect the knowledge, skills and attitudes attributed to critical thinking and clinical reasoning. They demonstrate the clinician’s reasoning and judgment when dealing with complex and challenging treatment situations, and the problem-solving process.
Billing and coding : Clinical documentation drives coding and billing. Accurate and compliant progress notes is critical for correct assignment of codes, which in turn, paves the way for maximum reimbursement, lower denial rates, and compliance.
Medico-legal requirements for documentation : Thorough and thoughtful documentation can provide a strong defence in the event of a medical negligence investigation.

What progress notes should include

Good and effective progress notes are accurate, complete, factual, organized, timely, compliant with health laws and meet facility standards. Information that may be included in a progress note:

All treatment provided to the patient in chronological order, along with length of session
Precise assessments of the patient’s response to the treatment (progress and/or lack of progress), and needs
Significant events, emergencies and action taken
Clinical impressions regarding diagnosis, and or symptoms
Treatment plan
Modification(s) of the treatment plan
Medications used by the patient
Rationale for orders written including medications and treatments
Treatment compliance/lack of compliance
Collaboration with other professionals
Referrals made/reasons for making referrals
Safety issues
Recommendations for revisions in the treatment plan

Progress notes entries in the EHR must include the author’s name, the date, and the time and be authenticated and attested with an e-signature.

Writing Effective Progress Notes

The UWSMPH study found that while residents understood the purpose and the key components of progress notes, they were unsure how to construct the notes and why specific details, such as past medical history, lab results, and vital signs, were included in the notes. Here are guidelines and tips to write effective progress notes:

Tell the patient’s story : Patients come to the clinician with a problem and when asked about it, will explain their experience during the history and physical exam. The clinician has to listen carefully to the patient’s story. The health professional then has to document a story that makes logical sense, recommends Osmosis. The patient’s story should form the clinician’s assessment.
Refer to specific components in the treatment plan : When writing weekly and monthly progress notes, specific components in the treatment plan must be referenced (www.dphhs.mt.gov). This will help establish the link between the progress note entry and the patient’s treatment plan and the outcome of treatment and any observation that could justify altering the patient’s course of treatment. A practical approach would be to summarize information about a series of treatment services into a single progress note.
a description of the incident with date and time of occurrence
assessment of whether the event is significantly different from the patient’s typical behavior
the reason for the event’s occurrence
how staff responded
recommendations for future interventions to be used
modifications to the treatment plan, medication, or the patient’s environment)
Ensure that assessment is documented correctly : Diagnosis documented will stick, notes Osmosis, and that’s why it’s essential for the clinician to ensure that the assessment is recorded correctly. If the provider is unsure about something, even that must be added in the assessment. The American Academy of Family Physicians (AAFP) instructs that the physician should “never assign a diagnosis unless that diagnosis has been confirmed by diagnostic testing, or is otherwise certain”. AAFP identifies uncertain diagnoses as including those that are: Probable, Suspected, Questionable, “Rule out”, Differential, and Working. If a definitive diagnosis cannot be established, the signs, symptoms, abnormal test result(s), or other conditions that prompted the patient encounter should be documented.
Write out a specific plan : The progress note should include the treatment plan, tests, and therapies. The rationale for ordering something or initiating a treatment should be explained. There should be sufficient specific details in the plan. For e.g., instead of writing ‘antibiotics’, the provider should list the name of the antibiotic and when it will be started, and explain the indication, duration, and reason for antibiotic choice as well as how response to treatment will be monitored.

To sum up, the clinician’s focus should be on developing and implementing a quality treatment plan and writing effective and useful progress notes. It’s essential to avoid abbreviations, and strictly avoid cutting and pasting from previous notes without editing and updating. Indiscriminate use of the EHR copy-paste function can lead to inconsistent progress notes and unnecessarily long progress notes. Healthcare organizations should have clear policies and procedures in place to ensure proper EHR documentation and provide education and training for clinicians to promote good progress notes. Medical transcription outsourcing is a practical way to ensure that EHR-integrated progress notes that are focused, concise, readable, organized, and useful.

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Patient Care

INFORMATION FOR

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Progress Notes

Hi everyone:

Most of you spend countless hours writing progress notes, so you should use this time well.

We write progress notes for two main reasons: to track a patient’s course and to communicate. Patients are complicated, and for consultants and cross-covering physicians, clear, concise notes are priceless.

Sadly, many notes are a mess of unfiltered, outdated, and irrelevant factoids. Let’s do better. Here are some precepts:

Copying and pasting: As I wrote last week, copying and pasting can crater your credibility. If you do copy and paste, ensure your notes are accurate and up to date.
Hospital summaries: Brief summaries at the top of the note can be helpful, but please synthesize. If Ms. Johnson was admitted three days ago with chills, fever, productive cough, and a right upper lobe infiltrate, just say she was admitted with pneumonia.
Focused physical exams: I’m skeptical that anyone is doing head-to-toe physicals on every patient every day, though some notes imply this. After admission, focus your exams. You don’t need to check pupillary responses every morning in patients with cellulitis (assuming they’re awake and talking), but you should update your skin exam, comparing your findings to the previous day (pictures are a bonus).
Targeted data: Don’t clog your note with reams of test results, especially radiology studies. Any reader can look them up, and no one relies on your notes to find the results of old head CTs. Show new tests and delete the rest.
Assessments: Don’t use assessments to reiterate raw data. Show your thinking. Tell readers if the patient is making progress or not (that’s why it’s called a “progress note”). For example: “Mr. Jones is a middle-aged man with a history of IV drug use, being treated with oxacillin for mitral valve endocarditis due to MSSA, now afebrile with negative blood cultures.” Or, if the diagnosis is uncertain, you might say “Mr. Jones has ongoing fevers despite antibiotics. Given that all cultures and imaging to date are negative, we’ve begun to suspect a non-infectious cause of fever.”
Follow up blood cultures
Start piperacillin-tazobactam, pending cultures
Everything in its place: Whether you use problem-based lists (on the floor) or system-based lists (in the ICU), organize your assessments and plans. For patients with diabetic foot ulcers, separate ulcer management (wound care) from diabetes treatment (insulin). For patients intubated with multilobar pneumonia, discuss ventilator management under “respiratory” and antibiotics under “ID.”
Be concise: Be brief . If your notes are too long, important information will get lost. Be thorough, but as with so much in medicine , less is more.

Writing effective progress notes will distinguish you as an internist. Good notes minimize the risk of dropped handoffs, they help consultants know what’s being asked of them, and they’re essential during emergencies. As a bonus, well-crafted notes save time, both for readers and for you.

Enjoy your Sunday, everyone. We flew in from Europe last night, and I look forward to seeing you again soon. Today, I’m driving down to New Jersey to visit my mom.

PS Pictures from Italy and Slovenia:

Featured in this article

Mark David Siegel, MD Professor of Medicine (Pulmonary); Program Director, Internal Medicine Traditional Residency Program

Compliance and documentation

How to write progress notes.

An illustration of a computer monitor, the text on the screen reads: "Progress Notes"

Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session.

Progress notes are aptly named: It’s a documentation of each session with your client where you share the progress you’re making on your treatment goals. Specifically, the treatment goals you aligned on in your treatment plan .

Simple, right? Not always, when you’re navigating insurer requirements and billing standards.

“I often hear from providers I work with that the concept of progress notes is ‘easy,’ but writing them in a compliant way is the hard part,” says Innocent Turner, Clinical Strategy and Quality Manager at Headway.

If the “rules” for writing compliant progress notes are confusing and vague, that’s because they’re left open for you to step in as the expert.

Other than following the advice in this article (or using a great template), Innocent recommends a quick gut check.

Read your progress notes back to yourself and reflect: Does this accurately portray what happened? Or is there an element of treatment that didn’t make it onto the page? If you feel like you’ve forgotten something, you probably did, but you can always figure out a way to include it.

This guide will help you understand the purpose of progress notes, what to include in your session documentation, and helpful templates and examples to get you started.

Use Headway’s free progress notes feature

When you’re a Headway provider, you get complimentary access to built-in documentation templates designed to make your note-taking fast, easy, and compliant.

Learn more about Headway’s EHR features and enhanced rates today; and start seeing insurance clients in less than 30 days.

What are progress notes?

Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session. Progress notes keep a record of the client's progress and the care you provide.

“When someone reads a note, they need to understand how your patient presented, what's going on with them right now, how you helped them, and how they received that help,” says Innocent Turner, LCSW and Headway’s Clinical Strategy Lead. “And if those questions are answered for the most part, you’re good.”

It’s also important that clear continuity of care is documented: While each note should lead into the next, each note should also stand alone, demonstrating a clear and comprehensive story of the client's progress through treatment.

You don’t need to include everything your client said in your progress notes, only what pertains to their treatment. If they spend the first 5 minutes complaining about their in-laws, don’t worry about capturing that in your documentation.

3 essential types of clinical documentation

A complete patient chart contains three core pieces of clinical documentation : an intake assessment, treatment plan, and progress notes.

Think of these as the “golden thread” : Your intake note should inform your treatment plan, and your treatment plan goals and objectives should be reflected in each progress note.

Here are the key details of the different types of documentation:

An intake assessment (intake note) should be created when initiating a treatment relationship with a client, and serve to document their current state and past experiences with mental healthcare.
A treatment plan establishes objectives and monitors progress. The plan includes a diagnosis and clearly establishes medical necessity for treatment.
Progress notes should demonstrate a clear and comprehensive story of the client’s progress through treatment. Clear continuity of care is important — each note should lead into the next but also stand alone.

Clinical documentation is a staple of any mental healthcare practice — it’s used to clarify the purpose of your sessions, justify the billing code used, and demonstrate a good picture of the patient’s current mental state.

These standards are outlined by the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), commercial insurers, and other regulatory agencies.

Your license or a particular insurer may have even stricter requirements than those set forth here.

6 progress notes requirements

Your progress notes need to contain the following details in order to effectively capture the progress you’re making with the client towards their goals.

1. Session details

These easy-to-note facts are required for all documentation, including your progress notes:

Start and stop time
Place of service: For telehealth sessions, include the client's location (for example: “home” or “office,” as well as a statement that the session was conducted via a HIPAA-compliance audio/visual platform)
Date of service
Patient name and a second unique identifier, such as their date of birth or an assigned ID number
Provider name and credentials

2. Person-centered details

Person-centered details are session-specific information that paints a helpful picture of the client's mental state and feelings, in their own words. Infusing specificity into your notes — such as the use of quotations from your client — helps insurers verify that the session was unique and veritable, and that you didn’t simply copy and paste from a previous session.

3. Patient-centered observations

Your notes should reflect a clinical assessment of your client’s current mental state in order to portray the full picture of their symptoms, diagnosis, and treatment. As a guide, each progress note should include at least three components of the mental status exam, such as descriptions of the patient’s appearance, behavior, alertness, reasoning, or mood.

4. Progress towards goal(s)

Make sure you identify progress towards the goal(s) outlined in your treatment plan, including whether the client made progress, regressed, or stayed about the same. Insurers review this item frequently; it's one of the most commonly missed. If you need to update the treatment plan, say that too. This will support the CPT code you're using and offer clarity if treatment goals change frequently (as they sometimes do).

5. Risk assessment

Because this is a sensitive area, it's especially important to clearly and completely document any risks in your progress note — it must also be unique to each session. Documentation of risk can be simple such as "client denies all areas of risk." That said, if you identify a risk, you are required to identify the client's risk level and create and document a safety plan. In these cases, you don't need to document the safety plan in the progress note itself, but you do need to include a note that the safety plan was created and the client agreed to it. For example, you might write "safety plan was discussed and reviewed with client."

6. Clinical path forward

Progress notes should outline the evidence-based practice used in the session, and comment on any changes in modality. You might also include any skills that may be helpful for clients to practice to help manage or reduce their symptoms, and why it would be helpful in reducing their symptoms.

Templates for progress notes

Because progress notes are required for every session through insurance, it’s helpful to leverage a template to help you complete your notes quickly and comprehensively.

Three of the most common progress note templates include:

SOAP notes : Subjective, Objective, Assessment, Plan. This format allows the provider to document their observations of the client and the session, and how they’re approaching the care plan. This is a popular type of template for talk therapy, especially used by licensed clinical social workers.
DAP notes : Data, Assessment, and Plan. These are similar to SOAP notes, but condense the subjective and objective sections into a single reflection of “data.”
BIRP notes : Behavior, Intervention, Response, and Plan. These notes help the provider reflect on the specific problem, or behavior, that’s being addressed in the session, then document what they tried and how it was received by the client.

Progress note example: SOAP note

Here’s an example of a progress note that meets most insurance carriers’ expectations for this type of clinical documentation. It follows the SOAP note template :

Subjective: A provider's own observations as well as the client's stated reasons for seeking care. Can include general references to the client's likely emotional state and the provider's summary of presenting problems.
Objective: References to specific and measurable elements from the session, such as physical appearance and the client's progress toward goals and modalities used during the session.
Assessment: A set of conclusions based on the provider's professional synthesis of both subjective and objective observations.
Plan: Next steps for the client, based on the provider's assessment, such as when the next session will take place, and what updates may be needed for the treatment plan.

Notice how it contains all 6 of the primary requirements for a compliant note.

Client Full Name: Katie Client Client Date of Birth: 9/9/1999

Date of Service: 3/08/2023 Exact start time and end time: 10:23 am – 11:20 am: 57 mins

Session Location: Telehealth, patient provided consent to telehealth, service performed on HIPAA compliant software

Subjective notes: Katie presents today’s session feeling “depressed.” She states that her mood has been “getting worse.” She reports that she has been struggling to get out of the house to enjoy social events that she is actually interested in, then becomes more frustrated with herself. She describes an increase in sleep issues, both difficulty falling asleep and staying asleep. Katie says that she “just wants to be better.” Katie continues to endorse low energy, loss of interest in activities, difficulty sleeping, and feelings of guilt, although she is not able to express the source of her guilt.

Objective notes: Therapist helped Katie process her feelings, provided in depth psychoeducation on guilt and how it relates to depression. Katie’s mood throughout the session was low, flat affect, her speech is low volume and soft. Therapist used the CBT triangle in session to assess Katie’s ability to identify patterns in behavior and thoughts. Katie required extensive guidance to understand the concept of the thought triangle. Therapist explored her feelings of guilt at length, and used socratic questioning to fully engage with past experiences that may be triggering guilt/shame. Therapist helped Katie process how her feelings influence her behavior (CBT triangle) and discussed in depth behavioral patterns that potentially are increasing her depressive symptoms.

Assessment: Katie continues to struggle with depressive symptoms, primarily guilt, making it difficult to engage with her surroundings as she desires. She lacks insight into her diagnosis, often saying things like “if I don’t want to be depressed then why am I depressed.” She required extensive socratic questioning to help her gain a little more insight into her diagnosis and feelings of guilt/shame. She denies SI/HI/AVH. She is struggling to make progress toward her goal of identifying triggers or past experiences that contribute to her feelings of guilt and worthlessness, as she requires redirection to provide relevant examples and/or to clarify her comments.

Plan: Therapist will continue to use CBT informed treatment to help Katie learn coping skills to manage depression symptoms and specifically guilt. For the next week, therapist asks Katie to consider her core beliefs and the source of her core beliefs. She was provided a worksheet to help clarify what core beliefs are and some potential sources. Therapist recommends meeting in one week, Katie will schedule the next session.

Client Signature and Date: Katie Client, 3/8/23

Clinician Signature and Date: Olivia Wells, LMFT, 3/8/2023

This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

Are progress notes just for insurance?

Progress notes are a requirement for billing sessions with insurance, but they also simply provide a written record of the care you delivered.

Even therapists who operate their practices through self pay should document progress notes. There may be times when thorough mental health care documentation becomes important, such as if your client transitions to a new provider or ends up in a health crisis or legal proceeding.

“If your patient is in some type of crisis — not even a mental health crisis but something like a car accident — they may end up in a hospital telling their care team, ‘yeah I see a therapist’,” says Turner. “Their care team might need to know what’s been going on in your care, so they can provide consistent care — like not giving medication that might cause issues.”

How to bill and code progress notes

It’s important to choose the medically appropriate billing code for the correct service delivered, and ensure your documentation supports and substantiates the service.

For talk therapists:

CPT code 90834: 45 minutes of psychotherapy, where the total time spent with the patient is 38–52 minutes
CPT code 90837: 60 minutes of psychotherapy, where the total time spent with the patient is 53–60 minutes

For psychiatrists and nurse practitioners:

CPT code 99204: 45-minute new patient outpatient visit, where the total time spent with the patient is 45–59 minutes
CPT code 99205: 60-minute new patient outpatient visit, where the total time spent with the patient is 60–74 minutes

Notes associated with 45-minute sessions should include a connection to the client’s diagnosis, symptoms, and plan, as well as details about how the session impacted their symptoms.

A 60-minute session note should include all the same details, as well as notes relating to medical necessity of why extra time was needed for more intensive treatment. This doesn’t have to be extensive – it just needs to be directly acknowledged. (You can find examples of medical necessity statements to help you craft your notes.)

It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.

Documentation of relevant aspects of client care, including documentation of medical necessity, should ideally be completed within 24 hours of visit, and no later than 72 hours.

Compliance— a Headway Guide

Navigating compliance can be time-consuming and stressful. We’re committed to changing that.

What are therapy intake assessments?

The intake assessment is your chance to get a deep understanding of your patient — and maybe connect some elements from their journey that they wouldn’t connect themselves.

How to write a mental health treatment plan

Whenever you want to change the goal of your therapy care, or the path you want to take with the client to reach that goal, you’ll want to document a treatment plan.

How to Write a Lab Report

Lab Reports Describe Your Experiment

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Lab reports are an essential part of all laboratory courses and usually a significant part of your grade. If your instructor gives you an outline for how to write a lab report, use that. Some instructors require a lab report to be included in a lab notebook , while others will request a separate report. Here's a format for a lab report you can use if you aren't sure what to write or need an explanation of what to include in the different parts of the report.

A lab report is how you explain what you did in your experiment, what you learned, and what the results meant.

Lab Report Essentials

Not all lab reports have title pages, but if your instructor wants one, it would be a single page that states:

The title of the experiment.
Your name and the names of any lab partners.
Your instructor's name.
The date the lab was performed or the date the report was submitted.

The title says what you did. It should be brief (aim for ten words or less) and describe the main point of the experiment or investigation. An example of a title would be: "Effects of Ultraviolet Light on Borax Crystal Growth Rate". If you can, begin your title using a keyword rather than an article like "The" or "A".

Introduction or Purpose

Usually, the introduction is one paragraph that explains the objectives or purpose of the lab. In one sentence, state the hypothesis. Sometimes an introduction may contain background information, briefly summarize how the experiment was performed, state the findings of the experiment, and list the conclusions of the investigation. Even if you don't write a whole introduction, you need to state the purpose of the experiment, or why you did it. This would be where you state your hypothesis .

List everything needed to complete your experiment.

Describe the steps you completed during your investigation. This is your procedure. Be sufficiently detailed that anyone could read this section and duplicate your experiment. Write it as if you were giving direction for someone else to do the lab. It may be helpful to provide a figure to diagram your experimental setup.

Numerical data obtained from your procedure usually presented as a table. Data encompasses what you recorded when you conducted the experiment. It's just the facts, not any interpretation of what they mean.

Describe in words what the data means. Sometimes the Results section is combined with the Discussion.

Discussion or Analysis

The Data section contains numbers; the Analysis section contains any calculations you made based on those numbers. This is where you interpret the data and determine whether or not a hypothesis was accepted. This is also where you would discuss any mistakes you might have made while conducting the investigation. You may wish to describe ways the study might have been improved.

Conclusions

Most of the time the conclusion is a single paragraph that sums up what happened in the experiment, whether your hypothesis was accepted or rejected, and what this means.

Figures and Graphs

Graphs and figures must both be labeled with a descriptive title. Label the axes on a graph, being sure to include units of measurement. The independent variable is on the X-axis, the dependent variable (the one you are measuring) is on the Y-axis. Be sure to refer to figures and graphs in the text of your report: the first figure is Figure 1, the second figure is Figure 2, etc.

If your research was based on someone else's work or if you cited facts that require documentation, then you should list these references.

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Sign in to your site’s geographic location:

Progress notes are vital to source data.

Progress notes are free-text entries by the investigator, coordinator or study team member that are inserted into the source record. Generally, these play a critical and highly undervalued role in the study process. Progress notes are often used to:

Clarify or confirm any data points that may appear as outliers, even before a query is issued.
Explain the clinical reasoning behind a PI’s assessment of eligibility, safety or patient medical history. This includes discrepancies or gaps in the EMR.
Document the steps a site has taken to mitigate a protocol deviation or safety event.

Overall, progress notes serve as vital evidence of effective PI oversight.”I teach all our CRA students about the importance of progress notes as a documentation tool for PI oversight,” said Dan Sfera, head of The CRA Academy , a training program for new CRAs. “A well-written progress note can make the difference between an unexpected, but minor, data discrepancy and a major protocol deviation that requires sponsor escalation. Without progress notes, monitors would not be able to fully confirm critical elements of the protocol, such as eligibility, protocol compliance or patient safety.”

EXAMPLE: In the example below, the PI has consolidated two items from the patient’s electronic medical record into one medical history item. Here, the PI documented his/her reasoning in a progress note. Without the note, an auditor could flag the discrepancy as a protocol deviation, casting doubt on the integrity of the source data.]

Because progress notes can be applied to any data point in real-time, CRIO eSource provides a far richer source of study data than the eCRF.

Benefits of eSource vs traditional eCRF

CRIO’s eSource system lets sites capture source data in real-time. Edit checks are applied at point of data capture to ensure protocol compliance. However, sometimes additional information is required to explain an event or data of a study participant. At any time, sites are free to add progress notes to a specific procedure within a visit; for a specific visit; or for a subject. CRIO client sites use this feature to ensure the clinical monitoring team can see their reasoning and thought processes. Oftentimes, CRIO’s built-in alerts are the trigger that ultimately prompts the coordinator to record a note. An unexpected value could lead to a suggestion of documenting an explanation.

By contrast, a traditional eCRF is a secondary data set that requires constant vigilance and attention to maintain. The eCRF contains only structured data. However, eCRF systems deprive the site from preemptively explaining insights about a procedure, visit, or subject that the sponsor would ask for upon reviewing the eCRF entries. As a result, queries within EDC systems often create redundant work for the site because they address information already addressed by the site in source. These queries can be extremely frustrating and demoralizing for sites. Sponsors should understand that these queries represent two extra workflows – one on the part of Data Management in issuing them, and one on the part of the site in answering them.

SIDEBAR: SITE EXPERIENCE

EDC systems limit the ability of Data Management to have direct access to study source material. As a result, I would often receive queries for information that had already been addressed within the source. Sometimes, I was addressing queries from both the data management and monitoring teams on the same data point, and the two teams were completely disconnected from each other. For instance, I would often have to address pathology or lab results, out of window procedures, out of window visits, non compliant medication adherence, specific investigator interpretations of results, and more, that were already documented and explained within my site’s source. This resulted in a lot of redundant work on my part, and none of this work would have been necessary if the data management team had access to the progress notes our team took the time to write.

John Vatkevich, CCRP (former Hematology and Oncology Site Coordinator of 8 years and current CRIO Employee)

What about the risk of PHI? The good news is that PHI is very rare.

One risk of a progress note within the CRIO system, is if the study team inadvertently inserts Protected Health Information. To be clear, inclusion of PHI in an eSource system is not technically a violation of the patient’s privacy. The study’s informed consent would have contained disclosure that the study sponsors and their representatives have access to the patient’s PHI. However, it is not best practice.

Fortunately, PHI in progress notes is relatively rare. We did an analysis of the progress notes saved by client sites in CRIO, and found only 5 progress notes containing PHI out of a sample of 1000. With further analysis, we estimate that 95% of similarly generated samples will have 0.054%-0.946% of progress notes containing PHI .¹

In other words, less than 1% of progress notes have PHI. This incidence is small enough that it can be managed through targeted site training. It’s a small cost compared to the significant value of enabling full and transparent access to site progress notes.

Final Thoughts

Clinical trials are complex. Accordingly, they always require a certain level of clinical judgment by the investigator. The progress notes tell the “story” behind the PI oversight. Altogether, progress notes are essential for sponsors to review as part of their obligation to perform oversight of quality. CRIO eSource enables real-time application of progress notes to any data point. This offers a significantly more comprehensive and rich data source for studies compared to the eCRF.

Related Reading: eSource makes the eCRF reliable, accurate and timely

_________________________________________________________

¹ Methodology: We extracted all 145,771 notes from 1 JAN 2023 through 20 APR 2023 within the U.S. client base. In this analysis, we assume each progress note is independent from another. We generated a random sample of 1,000 and had a trained employee review each note to flag PHI, using the 18 PHI identifiers used in HIPAA. We found 5 that had PHI – all names. There were no addresses, emails or phone numbers. The confidence interval was calculated by Clopper-Pearson intervals with the maximum allowable sample of 1,000. This could not be approximated by a standard normal distribution since the sample of progress notes containing PHI was so small.

JSCDM: Comparison of electronic health records and electronic source data in clinical research trials

The Journal of the Society for Clinical Data Management (JSCDM) recently published the original research article “Comparison of electronic health records and electronic source data in clinical research trials: a retrospective review” which was co-authored by Amelia Tian, CRIO Solutions Consultant, and Olivia Dennis, CRIO Analytics and Data Migration Manager, alongside Dr. Elena Christofides (Endocrinology...

21 CFR Part 11 Regulation Compliance Update

Compliance Update: The 21 CFR Part 11 Regulation is a cornerstone of conducting clinical trials in today’s world. The release of the regulation 1997 established guidelines for the use of electronic records and electronic signatures in FDA-regulated industries and had a significant impact on the pharmaceutical and medical device industries. The FDA began working on...

Leveraging eSource for Remote Monitoring: A CRO Clinical Team Manager’s Perspective–Q&A

We talked to Takoda Rolland, a Clinical Team Manager (CTM) from a Contract Research Organization (CRO), to learn about their experience implementing CRIO for remote monitoring on a large, global clinical trial. Question: How did you start using CRIO for remote monitoring as a CRO? I have long been a proponent of the potential of...

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Lab Report Format – How to Write a Laboratory Report

A typical lab report format includes a title, introduction, procedure, results, discussion, and conclusions.

A science laboratory experiment isn’t truly complete until you’ve written the lab report. You may have taken excellent notes in your laboratory notebook, but it isn’t the same as a lab report. The lab report format is designed to present experimental results so they can be shared with others. A well-written report explains what you did, why you did it, and what you learned. It should also generate reader interest, potentially leading to peer-reviewed publication and funding.

Sections of a Lab Report

There is no one lab report format. The format and sections might be specified by your instructor or employer. What really matters is covering all of the important information.

Label the sections (except the title). Use bold face type for the title and headings. The order is:

You may or may not be expected to provide a title page. If it is required, the title page includes the title of the experiment, the names of the researchers, the name of the institution, and the date.

The title describes the experiment. Don’t start it with an article (e.g., the, an, a) because it messes up databases and isn’t necessary. For example, a good title might be, “Effect of Increasing Glucose Concentration on Danio rerio Egg Hatching Rates.” Use title case and italicize the scientific names of any species.

Introduction

Sometimes the introduction is broken into separate sections. Otherwise, it’s written as a narrative that includes the following information:

State the purpose of the experiment.
State the hypothesis.
Review earlier work on the subject. Refer to previous studies. Cover the background so a reader understands what is known about a subject and what you hope to learn that is new.
Describe your approach to answering a question or solving a problem. Include a theory or equation, if appropriate.

This section describes experimental design. Identify the parameter you changed ( independent variable ) and the one you measured ( dependent variable ). Describe the equipment and set-up you used, materials, and methods. If a reader can’t picture the apparatus from your description, include a photograph or diagram. Sometimes this section is broken into “Materials” and “Methods.”

Your lab notebook contains all of the data you collected in the experiment. You aren’t expected to reproduce all of this in a lab report. Instead, provide labelled tables and graphs. The first figure is Figure 1, the second is Figure 2, etc. The first graph is Graph 1. Refer to figures and graphs by their figure number. For some experiments, you may need to include labelled photographs. Cite the results of any calculations you performed, such as slope and standard deviation. Discuss sources of error here, including instrument, standard, and random errors.

Discussion or Conclusions

While the “Results” section includes graphs and tables, the “Discussion” or “Conclusions” section focuses on what the results mean. This is where you state whether or not the objective of the experiment was met and what the outcome means. Propose reasons for discrepancies between expected and actual outcomes. Finally, describe the next logical step in your research and ways you might improve on the experiment.

References or Bibliography

Did you build upon work conducted by someone else? Cite the work. Did you consult a paper relating to the experiment? Credit the author. If you’re unsure whether to cite a reference or not, a good rule of thumb is to include a reference for any fact not known to your audience. For some reports, it’s only necessary to list publications directly relating to your procedure and conclusions.

The Tone of a Lab Report

Lab reports should be informative, not entertaining. This isn’t the place for humor, sarcasm, or flowery prose. A lab report should be:

Concise : Cover all the key points without getting crazy with the details.
Objective : In the “Conclusions” section, you can propose possible explanations for your results. Otherwise, keep your opinions out of the report. Instead, present facts and an analysis based on logic and math.
Critical : After presenting what you did, the report focuses on what the data means. Be on the lookout for sources of error and identify them. Use your understanding of error to determine how reliable your results are and gauge confidence in your conclusions.

Therapy Tools

Writing SOAP Notes, Step-by-Step: Examples + Templates

Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient’s care.

In a few sections, we’ll give a clear overview of how therapy SOAP notes are written, along with helpful templates and software you can use to streamline the process even further. If you’re looking for a more efficient, concise way to document your telehealth sessions, this helpful guide will be of value.

How To Write Therapy SOAP Notes

Therapy SOAP notes follow a distinct structure that allows medical and mental health professionals to organize their progress notes precisely. [1]

As standardized documentation guidelines, they help practitioners assess, diagnose, and treat clients using information from their observations and interactions.

Importantly, therapy SOAP notes include vital information on a patient’s health status. This information can be shared with other stakeholders involved in their wellbeing for a more informed, collaborative approach to their care, as shown:

Quenza SOAP Note Example Physical Therapy Software

It’s critical to remember that digital SOAP notes must be shared securely and privately, using a HIPAA-compliant teletherapy platform . Here, we used Quenza.

The S.O.A.P Acronym

SOAP is an acronym for the 4 sections, or headings, that each progress note contains:

Subjective: Where a client’s subjective experiences, feelings, or perspectives are recorded. This might include subjective information from a patient’s guardian or someone else involved in their care.
Objective: For a more complete overview of a client’s health or mental status, Objective information must also be recorded. This section records substantive data, such as facts and details from the therapy session.
Assessment: Practitioners use their clinical reasoning to record information here about a patient’s diagnosis or health status. A detailed Assessment section should integrate “subjective” and “objective” data in a professional interpretation of all the evidence thus far, and
Plan: Where future actions are outlined. This section relates to a patient’s treatment plan and any amendments that might be made to it.

A well-completed SOAP note is a useful reference point within a patient’s health record. Like BIRP notes , the SOAP format itself is a useful checklist for clinicians while documenting a patient’s therapeutic progress.[REFERENCE ITEM=”Sando, K. R., Skoy, E., Bradley, C., Frenzel, J., Kirwin, J., & Urteaga, E. (2017). Assessment of SOAP note evaluation tools in colleges and schools of pharmacy. Currents in Pharmacy Teaching and Learning, 9 (4), 576.”]

In the next section, you’ll find an even more in-depth template for SOAP notes that can be used in a wide range of therapeutic sectors.

Therapy SOAP notes include vital information on a client’s health status; this can be shared with other stakeholders for more informed, collaborative patient care.

3 Helpful Templates and Formats

With a solid grasp of the SOAP acronym, you as a practitioner can improve the informative power of your P rogress Notes, as well as the speed with which you write them.

This generally translates into more one-on-one patient time, reduced misunderstandings, and improved health outcomes overall – so the table below should be useful.

SOAP Notes: A Step-By-Step Guide

Podder and colleagues give a great overview of the different subsections that a SOAP progress note can include. Based on their extensive article, we’ve created the following example that you can use as guidance in your work. [1]

Occupational Therapy SOAP Notes

In Occupational Therapy , a SOAP Progress Note might include the patient’s injuries and their severity, home exercises, and their effectiveness.

Based on observations and interaction with their client, an OT professional might adjust their treatment program accordingly. [2]

Laid out in the S, O, A, P format on therapy notes software , they might look like this:

Digital SOAP note tools like Quenza, which we’ve used here, will automatically create PDF copies for download, sharing, or HIPAA-compliant storage in a centralized place.

Because SOAP notes are best created while a session is still fresh in their minds, therapists might look for mobile-compatible software. This way, notes can be made on the spot from a tablet or smartphone.

Recommended: How to write Occupational Therapy SOAP Notes (+3 Examples)

Applied Behavior Analysis SOAP Notes

SOAP notes also play a valuable role in Applied Behavior Analysis , by allowing professionals to organize sessions better and communicate with a client’s other medical professionals. Legally, they may also accompany insurance claims to evidence the service being provided. [3]

It is important to remember that ABA SOAP notes , as psychotherapeutic documents, must be stored privately. They may form part of a client’s overall medical file other therapy notes.

These illustrative Occupational Therapy SOAP Notes and ABA SOAP Notes also exemplify how versatile SOAP notes can be. [4]

It’s why the framework is a commonly used standard in sectors such as Physical Therapy , Nursing, Rehabilitation, Speech Therapy , and more.

5 Examples of Effective Note-Taking

Many therapy software systems help to speed up the documentation of progress notes through in-built templates and diagnostic codes. At the end of the day, however, clinically valuable notes require careful thought and judgment when it comes to their content.

Effective notes are generally: [5]

Written immediately following a therapy session. This way, a practitioner’s in-session time is spent focused on patient engagement and care ; writing notes immediately after helps minimize common mistakes such as forgetting details or recall bias.
Professional. An important part of patient Electronic Health Records , SOAP notes should be legible and make use of professional jargon to serve as a common frame of reference. They should be written in the present tense.
Concise and specific. Overly wordy progress notes unnecessarily complicate the decision-making process for other practitioners involved in a patient’s care. Brief, but pertinent information helps other providers reach conclusions more efficiently.
Unbiased: In the Subjective section, particularly, there is little need for practitioners to use weighty statements, overly positive, negative, or otherwise judgmental language. SOAP notes are frequently used both as legal documents and in insurance claims.
Utilize appropriate details, such as direct quotes: For a more comprehensive document that includes all the salient facts of an encounter.

An effective SOAP note is a useful reference point in a patient’s health record, helping improve patient satisfaction and quality of care.

3 Smart Software Solutions

In this section, we’ve reviewed three of the top practice management software systems offering helpful SOAP note functions.

These include SOAP note templates, discipline-specific codes, and treatment planning features that integrate with therapy progress notes.

Final Thoughts

With clear, consistent information on a patient’s health status and progress, therapists, psychiatrists, and counselors are much better equipped to manage their well-being. And while note-taking may not be glamorous, harnessing the right software can significantly reduce the time you spend on this vital part of healthcare .

SOAP notes play a pivotal role in streamlined, effective healthcare, and are a daily part of life for many practitioners. If you’ve tried and enjoyed using any particular templates, forms, or therapy notes solutions, let us know in a comment.

We hope this article has helped you streamline your note-taking. To put these tips into practice, don’t forget to try Quenza’s SOAP Notes tools for just $1 a month .

If you want to enhance the wellbeing of your clients more effectively, Quenza will give you everything you need to streamline your therapy notes, so you can focus on delivering the wellness results that matter.

^ Podder, V., Lew, V., & Ghassemzadeh, S. (2020). SOAP Notes. StatPearls. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK482263/
^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes.. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy
^ WebABA. (2020). Simple Guidelines for Writing SOAP Notes. Retrieved from https://webaba.com/2020/07/01/aba-practice-daily-simple-guidelines-for-writing-soap-notes/
^ Belden, J. L., Koopman, R. J., Patil, S. J., Lowrance, N. J., Petroski, G. F., & Smith, J. B. (2017). Dynamic electronic health record note prototype: seeing more by showing less. The Journal of the American Board of Family Medicine, 30 (6), 691.
^ Fusion Therapy. (2020). How To Write Therapy SOAP Notes. Retrieved from: https://blog.fusionwebclinic.com/soap-notes-for-occupational-therapy

thanks for info

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COMMENTS

5 Perfect Nursing Progress Notes Examples + How to Write
The next step in writing a perfect nursing progress note is to ensure you obtain objective data. Objective data include your patient's vital signs, laboratory or diagnostic test results, and any observable symptoms.For example, "Vital signs for Mr. Smith are B/P 150/98, P 90, R 20, Temp 101.4.
How to Write Nursing Progress Notes
A Good Nursing Progress Notes Example. There's nothing like reading an example to help you grasp a concept, so let's take a look at a sample nurse's progress note: 08.07.2022 — 10:30 am. Patient: Anne Example. The patient reported dizzy spells lasting up to 10 minutes once or twice a day over the last week.
How to Document a Patient Assessment (SOAP)
Document your impression of the diagnosis (or differential diagnosis): "Impression: community-acquired pneumonia". If the diagnosis is already known and the findings of your assessment remain in keeping with that diagnosis, you can comment on whether the patient is clinically improving or deteriorating: "On day 3 of treatment for ...
3 Tips to Write Progress Notes
The subjective element of a SOAP note is what the individual shares with their health professional. The objective piece is what the health professional determines through a physical exam, laboratory results, or imaging. An assessment is when the health professional provides a diagnosis. The plan is when the health professional decides what's ...
How to Write Progress Notes [Ultimate Guide for 2022]
In general, all progress notes should include a variation of the following: Demographic information: You may include your client's name, date of birth, start and end times of each session, and your signature. Description of client behavior: Describe your client's behavior, appearance, mood, symptoms, diagnosis, changes to medications, and a ...
How To Write A Lab Report
Introduction. Your lab report introduction should set the scene for your experiment. One way to write your introduction is with a funnel (an inverted triangle) structure: Start with the broad, general research topic. Narrow your topic down your specific study focus. End with a clear research question.
How to Write a Nursing Progress Note: Tips and Infographics from
It is crucial to include all the details in the progressive note to compare the status of the patient on the path of recovery to the date of entry and track the progress of the patient. This helps to improve the quality of care and follow-up on all actions taken. We found a great, even better, short YouTube video explaining what a nursing ...
Ultimate Guide to Progress Notes
Response (R): This part of the progress note relates to information regarding how the patient responded to the practitioner's intervention and treatment strategies. Plan (P): The note concludes with comments on the patient's plan, in particular, the date and time of the next session and the focus of that session. 3.
01.06 How to Write A Nursing Progress Note
The goal of the progress note is to write a chronological narrative of the shift including any issues you may have come across. For instance, you can write a note after you complete your initial assessment. It may look a little something like this: (date/time: Physical assessment completed. VS WNL.
Your note, your way: how to write an inpatient progress note accurately
Introduction. The five key elements of medical writing include: history and physical examination, progress note, discharge summary, peer-reviewed publication and grant proposal [].Among these types of medical writing, only progress notes need to be written for each patient daily in the inpatient setting and serve as an important component of team communication between members of the medical team.
5 Nursing Narrative Note Examples + How to Write
3. Non-Descriptive or Non-Precise Terminology: The nursing narrative note should create an image or story in the reader's mind. Therefore, precise and descriptive terminology is necessary. For example, instead of charting "bed soaked with urine," the nurse should write "Pt.
Guidelines to Write Good Progress Notes
Writing Effective Progress Notes. The UWSMPH study found that while residents understood the purpose and the key components of progress notes, they were unsure how to construct the notes and why specific details, such as past medical history, lab results, and vital signs, were included in the notes. Here are guidelines and tips to write ...
Progress Notes < Yale School of Medicine
Progress Notes. August 21, 2022. Hi everyone: Most of you spend countless hours writing progress notes, so you should use this time well. We write progress notes for two main reasons: to track a patient's course and to communicate. Patients are complicated, and for consultants and cross-covering physicians, clear, concise notes are priceless.
How to write progress notes (with examples)
In these cases, you don't need to document the safety plan in the progress note itself, but you do need to include a note that the safety plan was created and the client agreed to it. For example, you might write "safety plan was discussed and reviewed with client." 6. Clinical path forward.
How to Write a Lab Report
Title Page. Not all lab reports have title pages, but if your instructor wants one, it would be a single page that states: . The title of the experiment. Your name and the names of any lab partners. Your instructor's name. The date the lab was performed or the date the report was submitted.
PDF How to Write Lab Notes and Lab Reports
1. Do not compile a complete lab report in the lab notebook. The lab notebook should include a record of what was done, how it was done, and what the results were. The records should be substantial enough that a knowledgeable person can read, comprehend, and repeat the experiment if needed. 2.
Labs 2
Demonstrates how lab results return in eClinicalWorks, how they can appear in the patient notes, and on the patient web portal
PDF Write a Result Note and Release Results to MyChart
Write your result note using the result report and any additional information you might need from the chart. Add recipients or clear the Route check box, if you aren't routing the result note. If necessary, adjust the message's priority. Your note will be filed to the chart with the result. Select the Also file Progress Note check box if ...
Progress Notes are Vital to Source Data
Progress notes are often used to: Clarify or confirm any data points that may appear as outliers, even before a query is issued. Explain the clinical reasoning behind a PI's assessment of eligibility, safety or patient medical history. This includes discrepancies or gaps in the EMR. Document the steps a site has taken to mitigate a protocol ...
How to keep a lab notebook
One of the hardest things in maintaining a lab notebook is deciding when to write a thorough entry and when to write a cursory one. I always start by writing down a minimum amount of information for every experiment. This generally includes date, time, location, protocol parameters, where the data is stored, and—if I'm using code—the script ...
Proper Documentation for Pathology and Laboratory Reports
A provider must document in the patient's medical record medical necessity for pathology and laboratory services, as well as indicate that he or she ordered the tests. The ordering physician must also note in the patient's record how he or she used the findings to select a diagnosis and a treatment plan. The most commonly performed ...
Lab Report Format
A typical lab report format includes a title, introduction, procedure, results, discussion, and conclusions. A science laboratory experiment isn't truly complete until you've written the lab report. You may have taken excellent notes in your laboratory notebook, but it isn't the same as a lab report. The lab report format is designed to ...
Writing SOAP Notes, Step-by-Step: Examples + Templates
Documentation is never the main draw of a helping profession, but progress notes are essential to great patient care. By providing a helpful template for therapists and healthcare providers, SOAP notes can reduce admin time while improving communication between all parties involved in a patient's care. In a few sections, we'll give a clear overview of how therapy SOAP notes are written ...
DeepES: Deep learning-based enzyme screening to identify ...
Progress in sequencing technology has led to determination of large numbers of protein sequences, and large enzyme databases are now available. Although many computational tools for enzyme annotation were developed, sequence information is unavailable for many enzymes, known as orphan enzymes. These orphan enzymes hinder sequence similarity-based functional annotation, leading gaps in ...

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✅ Details that are important to include in a competent nursing progress note

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🔗 References

Ultimate Guide to Progress Notes | Carepatron

Understanding progress notes in healthcare

Difference between progress notes and psychotherapy notes

When should you write progress notes?

Tips for writing good progress notes

Things to avoid when writing progress notes

HIPAA compliance for secure progress notes

Secure storage of progress notes

Encryption and remote storage

Electronic protected health information (EPHI)

Moving forward with compliance

Different progress note templates

Examples of excellent progress notes

1. Therapy progress note

2. Psychology progress note

3. Physical therapy progress note

Progress notes in the digital age

Electronic health records (EHR)

Electronic vs. paper progress notes

Electronic notes

Handwritten notes

The clear choice

What should you look for in progress note software?

Final thoughts

Further reading

Related Articles

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01.06 How to Write A Nursing Progress Note

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Your note, your way: how to write an inpatient progress note accurately and efficiently as an intern

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5 Nursing Narrative Note Examples + How to Write

What Is A Nursing Narrative Note?

Guidelines and Tips to Write Good Progress Notes

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Progress Notes

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What are progress notes?

3 essential types of clinical documentation

6 progress notes requirements

1. Session details

2. Person-centered details

3. Patient-centered observations

4. Progress towards goal(s)

5. Risk assessment

6. Clinical path forward