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ERK4499 - SECTION 10: THE PROGRESS NOTE

 

Section 10: The Progress Note

There are several functions that need to be performed in each treatment session, and a well designed progress note or case note will allow clinicians to record in a concise manner each of these functions. First, each session has to include an updated mini-assessment of the client’s status and record any significant changes to that status from what was seen in the initial psychosocial assessment.

At each point of treatment, there are professional obligations to the safety and well-being of the client, and this mini-assessment is a fundamental part of the process of providing and recording due diligence in reviewing the status of the patient in these areas. With more stable clients, this mini-assessment process is not quite as urgent in terms of the patient’s overall well being and safety. However, there are many circumstances that can change a client’s status from stable to unstable in a relatively short period of time, so a detailed record of these items is considered essential to good practice for healthier clients just as it is for less healthy clients.

With more disturbed clients, a consistent, session by session review of mental status, safety risks, substance abuse symptoms, changes in medication and medication compliance, new psychosocial stressors, and alterations in the client’s system of support must be considered an essential part of good professional care. It is considered good due diligence to assess these items within each session. Accordingly, these are all items that are to be found in a good progress note template.

The next item that must be contained in a progress note is a record of the problems addressed in each session and a record of the specific interventions used to treat those problems. It is also useful to include a section that identifies the specific objectives for each individual session. If a clinician is using a good treatment plan and has integrated his/her treatment plan with a progress note template, then these components of the progress note would align well with key problems to address and the approaches identified as being part of treatment.

The problems that are being addressed in the session can be recorded in a narrative format that will allow the clinician to include other important topics of discussion, including in areas that are not identified as targeted problems within the treatment plan. There are some items that will require the clinician to revise the treatment plan to target important and emerging areas, and there will be some items that are peripheral to the treatment plan, but still important to note.

Interventions can usually be classified according to a set number of treatment approaches, and a check box format can be used for the most commonly applied treatment methodologies, such as Cognitive Behavioral Therapy or Relapse Prevention. This format would create some efficiencies and allow for more rapid recording of which approaches are utilized in each session.

Interventions can also consist of referrals to other providers or to outside resources such as twelve-step groups, as well as clinical “homework” such as reading materials, self-help forms and workbooks, and relapse preventions plans. Interventions may also include such items as contracts made between the clinician and client around safety issues, like suicidal ideation. All of these different kinds of interventions should be recorded in the progress note for the session in which the recommendations are made. In subsequent sessions, these interventions can be tracked and information recorded about client follow through.

Finally, there should be a section that records the clinician’s assessment of the session and the progress made towards reaching treatment goals, and another section that identifies tentative plans for the following session.

Progress notes should always have the date of the session and the signature of the clinician attesting to the completion of the progress note on that date. Since many insurance payers reimburse based upon set increments of time, it is also advisable to include the start and end time for any session.

All of these items can be seen on the template below.


                                                  Pat R. Clinician, LCSW
                                                    PROGRESS NOTES

Client Name:______________ Date of Session: _____ Start time: ______ End time: _______

Other parties present / Relationship to client: 

__________________________________________________________________________________________________________________________________________________________________________________ 
Objectives for session: 

__________________________________________________________________________________________________________________________________________________________________________________ 

Changes in medications: __None Changes:_________________________________________________________

Changes in biopsychosocial status (health, work, family, relationships, etc.): __None Changes: _________________________________________________


Current Assessment of Functioning (1=mild 2=moderate 3=serious 4=severe 5=extreme)

Mental status: __Normal __Lessened awareness __Memory deficiencies __Disoriented __Disorganized __Delusional __Hallucinating __Vigilant __Other (list):
Suicide/violence risk: __None __Ideation only __Plans __Threat __Gesture __Rehearsal __Attempt
Mood: __Normal __Anxious __Depressed __Irritable __Expansive __Euphoric __Dysphoric __Tearful
Affect: __Normal/appropriate __Unconstrained __Blunted/Restricted __Inappropriate __Labile __Flat
Insight: __Good __Impairments in insight Judgment: __Good __Impairments in judgment
Behavioral problems: ___None __Aggressive __Impulsive __Angry __Oppositional __Agitated
Substance misuse: __None __Level of misuse (list substance(s)) _______________________________________________________________

Data / Issue(s) Addressed: 

 _________________________________________________________________________________________________________________________________________________________________________________ 


Intervention(s) Utilized: __Cognitive __Supportive __Educational __Insight oriented __Solution focused __Systems  __Behavioral __EFT __DBT __Relapse Prevention __Other(list) ____________________________________________
Resources provided (e.g., handouts, contracts): __________________________________________________________

Referrals made: 

__________________________________________________________________________________________________________________________________________________________________________________ 

Assessment / Progress made towards achievement of treatment goals / Effectiveness of interventions: 

__________________________________________________________________________________________________________________________________________________________________________________ 

Topics / Plans for next session: 

 _________________________________________________________________________________________________________________________________________________________________________________ 


Signature: ____________________________________

 

 Progress Notes with More Complex Cases

For more complex cases, with co-morbid problems, multiple providers and a case management component, it is a more complex picture to determine what will be included in a progress note. In hospital settings, for instance, each member of a team of providers may have very clearly defined and limited roles to play in the performance of a client’s overall treatment plan.

One member of a team may supervise the distribution of medications, another may conduct supportive group sessions, while still another may be working to find community resources to support the individual’s return to the community. Each of these players must maintain a record of his or her actions – and the progress made towards fulfillment of the treatment objectives – but not every member of the team may be asked to perform a thorough assessment of the client’s mental status or have complete information about current psychosocial stressors.

In such instances, the progress note may be directly connected to the more complex treatment plan template noted in the previous section. The treatment objective would be identified, along with the intervention and the party assigned to perform the intervention, then a brief record made of the actions in a DAP (Data, Assessment, Progress) or SOAP (Subjective, Objective, Assessment Progress) format. This general approach is shown below:


Client Name:______________ Date of Session: _____ Start time: ______ End time: _______

 Changes in medications: __None Changes:_________________________________________________________

Changes in biopsychosocial status (health, work, family, relationships, etc.): __None Changes: _________________________________________________


Current Assessment of Functioning (1=mild 2=moderate 3=serious 4=severe 5=extreme)

Mental status: __Normal __Lessened awareness __Memory deficiencies __Disoriented __Disorganized __Delusional __Hallucinating __Vigilant __Other (list): 
Suicide/violence risk: __None __Ideation only __Plans __Threat __Gesture __Rehearsal __Attempt 
Mood: __Normal __Anxious __Depressed __Irritable __Expansive __Euphoric __Dysphoric __Tearful
Affect: __Normal/appropriate __Unconstrained __Blunted/Restricted __Inappropriate __Labile __Flat
Insight: __Good __Impairments in insight Judgment: __Good __Impairments in judgment
Behavioral problems: ___None __Aggressive __Impulsive __Angry __Oppositional __Agitated 
Substance misuse: __None __Level of misuse (list substance(s)) _______________________________________________________________

 
       Treatment             Objective        Intervention        Party Assigned to                     Intervention
     

 

Data: 

__________________________________________________________________________________________________________________________________________________________________________________ 


Assessment:

__________________________________________________________________________________________________________________________________________________________________________________ 

Progress:

__________________________________________________________________________________________________________________________________________________________________________________ 


Signature: _____________________________________

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