Of all the things that therapists have to do, therapy notes and note-taking is probably one of the most tedious and confusing things we do. It is also an absolute necessity.
Progress notes are the way you document that a client participated in and completed a session with you. Depending on the billing process you have, a completed therapy note may also be the way a claim is generated. Documentation also demonstrates your competency and shows how a client’s needs have been addressed.
Before talking about therapy notes such as progress notes, know this: not all therapy notes are created equal. There are progress notes and there are psychotherapy notes. Most therapists keep some form of therapy notes but they are very different and treated differently under HIPAA.
- Psychotherapy notes are detailed, private notes that a therapist may keep. These notes may contain observations, impressions and other details of the session. These notes do not follow a standard format and are stored separately. These types of notes have special protection under HIPAA and are NOT contained in the client’s record.
- Progress notes are part of the client’s record that provide details about the client such as diagnosis and assessment, symptoms, treatment and progress towards treatment goals. They follow a standard format (e.g., SOAP, BIRP, etc.) and ARE included as part of the client’s record.
SOAP NOTE 101
Most mental health clinicians utilize a format known as SOAP notes. SOAP is an acronym that stands for:
S – Subjective
O – Objective
A – Assessment
P – Plan
A SOAP note is a progress note that contains specific information in a specific format that allows the reader to gather information about each aspect of the session.
Now, to be honest, most clinicians weren’t “trained” on SOAP notes as part of graduate training. Chances are you picked up some therapy note-taking skills along the way. Some of you might be doing long, narrative notes that contain way more information than is appropriate for a progress note. (See progress vs. psychotherapy note descriptions above) So, let’s break down a SOAP note and take a closer look at it contains.
Subjective – This section contains information relevant to what the client reveals in the session. This may be the client’s chief complaint, presenting problem and any relevant information. This information may include direct quotes from the client. This section also includes things discussed during session. For example, you may have discussed your client’s complaint of not sleeping well and sleep hygiene. Use words like “Discussed” or “talked about” or “reviewed” when describing things talked about in session.
Objective – The objective section contains factual information. Such objective details may include things like a diagnosis, vital signs or symptoms, the client’s appearance, orientation, behaviors, mood or affect. For example, client is oriented x4 (person, place, time, situation), client appears disheveled.
Assessment – This section is the place where you, as the clinician, document your impressions and interpretation of the objective and subjective information. This documentation may include clinical impressions related to factors such as mood, orientation, risk of harm as well as assessment of progress towards goals. Here you want to describe your impressions. For example, client appears to understand the new goal.
Plan – This section documents what the next step is for the client. What do you, as the clinician, plan to do with the client at the next session? This is also the place to document things like the anticipated frequency and duration of therapy, short and long term goals as well as any new goals. Be sure to note any homework assignments or tasks you’ve given your client.
It sounds like an easy format to follow but it does take some practice.
Tips for Writing Progress Notes
As with any clinical documentation, you want to be sure you are including pertinent information. You also want to avoid errors that can at best be annoying and at worst, place you in legal jeopardy.
First, breathe. No therapy note is 100% perfect. Depending on who looks at it, there will always be something that could be written more clearly, more detailed, less detailed…something. The key is to write clear, thorough notes in a timely and consistent manner.
Here are some tips for writing solid progress notes:
- Write your note as if you were going to have to defend its contents.
- Use clear and concise language. Avoid using slang, poor grammar or odd abbreviations.
- Pay attention to spelling, person and tense.
- When quoting a client, be sure to place the exact words in quotation marks.
- Keep your notes short and to-the-point. Be clear and complete. Avoid expanding beyond what is required for each section.
- Be mindful of correct dates, times, spelling of names.
- Avoid making subjective statements that cannot be substantiated. When making subjective statements, include pertinent evidence. For example, client appears anxious as evidenced by wringing his hands, excessive tapping of fingers, hyperventilation.
- Never, ever alter a record using any type of correction eraser/tape/fluid/mark outs/scratch outs.
Errors happen. Even the most careful note writer will make mistakes. If you find an error, resist the urge to just scratch it out or otherwise alter the record. Omissions, deletions and altered records create suspicion about its validity. The best way to correct an error is to use an accepted procedure for error correction. Here’s an example of one such procedure:
If you find an error, use a single strike-through (
abc), write “error” next to it, and initial the error. Write in the correction and initial the correction. This way, the reader can see the original error, see the corrected information and see who made the correction. A word of caution: you want to be the one to correct your own records.
With a little practice, you can be a skilled progress note writer.
TheraPlatform offers progress note templates that take all the guesswork out of remembering all the details of SOAP. Choose from an entire library of templates that you can use to streamline your documentation process. You’ll be able to efficiently and confidently complete your notes which means less time spent stressing over documentation. And all it takes is a little SOAP.