How To Write Therapy Progress Notes Like a Pro with These 5 Tips From a Psychologist

What’s one part of your job as a therapist that you’d like to improve?

I actually went around asking my colleagues and friends that same question. 

Can you guess what the most popular response was?

If you said writing progress notes — you’re spot on.

A lot of my fellow mental health professionals specifically mentioned writing progress notes. They wanted to find a more efficient and effective way to write notes. They want to keep notes concise while including all the required information.

Despite their importance, it’s common to find that many of us haven’t been given good guidance on writing therapy notes. Progress notes were touched on during grad school. But, when I graduated, I found that I didn't really know how to write them well at all. They were taking up a huge chunk of my time, where I could be seeing another patient or running personal errands. I found this frustrating. 

Like most of you are doing now, I had to learn on the job. To help you out, I’m going to share the top 5 tips I learned from my years of personal experience as a psychologist. 

The Foundation of Good Progress Notes

Writing good progress notes is a skill that will continue to build as your experience grows in the field. Setting a good foundation will help you in the long run. Note taking will become easier and quicker with experience. This is a part of your responsibilities that will always exist. It's important to not only write notes efficiently, but the quality of them matters as well. 

Another reason to tackle this task is because they're often required by insurance companies. This applies whether you're an in or out-of-network provider. 

So, how do you know if your notes are “good”? 

The foundation of great notes are ones that offer complete information while being concise. That means getting to the point. Although they seem like opposing ideas, it’s important to keep these two words in mind. 

How To Write Therapy Progress Notes That Are Complete 

Everyone has different styles of writing, so notes don’t need to be written identically. There are a few items that need to be in every progress note though. For a note to be considered complete, it should include these essential components:

• Time and date of the session
• Official mental health diagnosis 
• Corresponding DSM-5 or ICD-10 codes
• Current treatments or therapy
• Results of clinical tests
• Any medications the client takes
• Safety concerns or health risks
• Any symptoms the client may exhibit

As you can see, it doesn’t mean writing a blow-by-blow account of the session. It's simply including all the relevant information. 

How To Write Therapy Progress Notes Concisely

Let’s say you wanted to look back at an old note to track areas of improvement in your client. If it's lengthy with too many extra details, it's going to take you longer to go through the note. 

One of the main reasons for keeping progress notes is the ability to refer back to them. Not only that, but be able to understand what is written. If you’re used to being quite wordy, there can be a bit of a learning curve in balancing it with being concise. 

I struggled with writing progress notes. Improving these skills felt like stumbilng up a rocky slope without water. No matter how slow-going the journey feels, I'm confident you'll get there too. All it takes is consistent practice.

Lesson #1: Know When To Take Notes

How do you know when it's an appropriate time to take notes?

Don’t worry, it’s acceptable to write notes in front of your client, as long as it's done in moderation. You can keep yourself on track by knowing what information you need. Keeping tabs on the relevant details that come up will help you remember what to write. Identifying a main theme or idea for each session can help with this. 

You can ask yourself a few questions – What does the client want to achieve? What is the purpose of this therapy appointment? 

The answer to those questions can help shed some light on what to pay attention to during the session. Some common examples of themes during sessions are:

• Adjusting to a new environment
• Coping with the death of a loved one
• Adjusting to new responsibilities
• Exploring underlying reasons for self-esteem issues

If you’re taking notes the entire time, it could make it difficult to concentrate. You’ll likely include too much information. If you tend to struggle with that, then writing them right after the session ends might be better for you. 

Any of the little details that don’t relate to the main focus aren’t necessary. As they say, don’t sweat the small stuff.  

Lesson #2: Focus on Quality Over Quantity to Write Better Therapy Progress Notes

Concise note-taking isn’t just what you write, it's also about how you write. High-quality notes are direct, relevant, with a professional tone, and easy to understand.

If you want to be concise, it's helpful to work on being practical about your word choices. Two things you can train yourself to avoid are two V’s: verbose (highly technical) and vague words.

Both verbose language and vague statements can make your notes pretty lengthy. This makes it harder for you to review them. If you're sharing notes with other therapists, they could find it difficult as well. You'll want to make sure the notes are easy to comprehend, no matter how much information is included. 

Have you ever thought about timing yourself?

In general, good progress notes can be written in 10 minutes or less. If you set a goal of completing your notes in a brief amount of time, it can help you cut down on nonessentials. This will improve the quality of your notes. 

Lesson #3: Focus on Facts and Specific Statements

One of the most effective methods I’ve found for reducing the length of my notes is to stick to the facts. This also allows me to be hyper specific. There aren’t any random details that don’t add value to the big picture. 

Prioritizing facts over subjective statements can also help with this. Although your notes are your observations, they aren’t meant for subjective or judgemental opinions.

For example, “the client is a bad partner” would be subjective. 

You could instead say something like, “the client talks over their partner, making conflict resolution a challenge.” Taking note of a specific event, statement, or habit that led you to your opinion accounts for the facts. 

Providing more specificity can also help keep your notes objective while remaining concise. This falls into the same line of thought as my previous tip about using vague words or phrases. 

Here are some examples of vague vs. specific statements:

• Vague: The client is feeling anxious.
• Specific: The client is experiencing excessive worry due to her company’s layoffs.
• Vague: The client looked tired and sleepy during the session.
• Specific: The client noted he was having difficulty sleeping and often feels unable to focus during the day, including during the session.

Lesson #4: Use and Customize Therapy Progress Notes Templates

Advancements in technology have brought along some great tools. These tools include templates and progress note generators that you can use.

If you're struggling with their progress notes, I almost always recommend using templates. They make it easier and less time consuming to write notes. They also help with making them more specific and effective too. 

Some therapists might tell you that progress notes templates aren’t for them. Usually they either haven’t found the right one for them, or haven’t been taught how to maximize its potential. If you’ve tried templates before and found that it didn’t align with the way you like to take notes –  you can customize it so that it does.

Everyone has their own style and individual approach to therapy and note taking. Feel free to tweak templates as you see fit – if you like checkboxes, add those in for things you’d normally check off. The possibilities are endless. You can add areas for session themes, prescription medications, or your current treatment plan. If your client’s overall appearance is tied to their mental health and progress, you can include that too.

If you want to start off more simply, you can work with a data, assessment, and plan (DAP) template. These cover most clinical bases and can help you fine-tune your notes.

To make things even easier, use a note generator tool. Our team at Clarity Cooperative spent the last few years developing our Therapy Notes Generator. The best part of it is that you can customize and arrange elements and sections in the order you like. If you set it up once, it’ll stay that way for your next use. 

Lesson #5: Write and Review

Having multiple factors to consider and remember in order to write great and effective progress notes can feel counterproductive for some therapists. This could boil down to the fear of making a mistake or the desire to do things perfectly.

Even with a therapy progress notes template, you could worry about whether to include certain details. The two biggest roadblocks of fear and perfectionism can still get in the way. 

For this, there’s one effective (okay, a little cliche) solution.

Like Nike is always saying – Just do it.

I can’t speak for everyone in our field, but many that I know didn’t get the most extensive training in writing case notes. I’ve learned most of what I know from practical application. 

What works for me might not exactly be the ideal way for you – the best way to figure that out is through experience. Sure, there’s some trial and error that comes with this. Any mistakes made along the way are lessons you can learn from to continue improving your skills. Eventually, you’ll notice that progress notes are a piece of cake. 

Repetition is key. Getting into the habit of writing progress notes in 10 minutes or less can simplify your process. You can also identify areas that are slowing you down, and where you might need improvement. 

Regularly reviewing your notes can also help you improve. You'll be able to see the phrases you use often, and what information is important or extraneous. You can also create a list of the phrases you use often with checkboxes. Adding these to your customized template can make it even easier to write complete, concise, and effective progress notes. 

Bonus Lesson: Ask for Help and Utilize Our Therapy Notes Generator Tool

Having a colleague or mentor review your notes can be an excellent way to get valuable, constructive feedback. They can also help you calm any fears or anxieties you may have about your work. 

Clarity Cooperative also offers valuable resources and a customizable Therapy Notes Generator tool. Our tool helps you put together progress notes quickly and easily. 

If you’d like some more support, our community is a great place to ask questions and connect with other professionals around the country. 

Try out our Pro subscription today with a risk-free 30 day trial and access all of our features, including our practice toolbox. 

All of our resources and tools are made by therapists, for therapists — so you can rest assured, we’re thinking of your needs and wishing you success.