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 wanted to find a way to write progress notes more efficiently and effectively – keeping notes concise while including all of the required information.

Despite their importance, it’s actually common to find that many of us haven’t been given good guidance on writing therapy notes. 

Like most of you are doing now, I had to learn on the job, and 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 as note taking will become easier and quicker, and this is a part of your responsibilities that will always exist. It's important to not just write notes efficiently, but the quality of them matters as well. 

Another reason to really tackle this task is because they are often required by insurance companies, whether you’re an in or out-of-network provider. 

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

The foundation of great notes are ones that offer complete information while remaining concise, and 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, but there are a few items that need to be in every progress note. 

For a note to be considered complete, it means including all of the essential components listed here:

• 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, but simply including all of 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 really lengthy with too many extra details, you might find it more difficult and time consuming to go through. 

Being able to easily refer back and understand previously written notes is one of the main purposes of keeping them. If you’re used to being quite wordy, there can be a bit of a learning curve in balancing it with being concise. 

As someone who struggled with writing progress notes, I can tell you that improving these skills can feel like stumbling up a rocky slope without water. No matter how slow-going the journey might feel, I’m confident you’ll get there with continued 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 totally 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 and keeping tabs on the relevant details that come up. 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, and 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 and can be left out. 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 really 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 instantly make your notes pretty lengthy and make it harder for you to review them quickly. If you’re sharing your notes with other therapists, they could also find it difficult to comprehend, despite how much information you’ve 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 and improve the overall 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 because 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

Templates and progress note generators are some of the beautiful tools that have come along with advancing technology. 

If anyone’s struggling with their progress notes, I almost always recommend using a template. They not only make it easier and less time consuming to write notes — they help with making them more specific and effective too. 

Some therapists might tell you that 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 totally 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 which covers most clinical bases and can help you fine-tune your notes.

To make things even easier, our team at Clarity Cooperative spent the last few years developing a Therapy Notes Generator tool. 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 absolutely perfectly.

Even with a therapy progress notes template, one could continue to have concerns about whether to include certain details or not. The two biggest roadblocks of fear and perfectionism can still get in the way. 

For this, there’s one effective (okay, maybe 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 just 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 overall process and help you identify areas that slow you down, and where you might need some improvement. 

Regularly reviewing your notes can also help you improve by seeing the kinds of phrases you often use, and what information is important or possibly extraneous. You can also create a list of the phrases you use frequently 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, as well as calm any fears or anxieties you may have about your work. 

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

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.