There are a few progress note basics that every therapist should know. But most educational programs do not focus on how to write notes. They focus more on therapy than notes. I think they assume we will learn progress note basics on the job. But if you are learning from people who aren’t good at writing notes, then it’s hard to get it right. Learn how to make great notes with S.O.A.P. or D.A.P format.
Progress notes need to be written for each session you have with a client. They should be based on the client’s treatment plan and describe the progress the client is making on treatment plan goals. You can deviate from the treatment plan in a session. However, this should be documented in the progress note. An example is to write, “Client was in crisis over housing issues so therapist deviated from treatment plan goal of working on addiction triggers.”
There are 2 basic ways to write Progress Notes
The subjective is information told to the therapist by the client. It is the client’s thoughts, feelings, plans, goals, issues and their intensity and its impact on their life. Statements from the client can be included too but these should be brief parts of what they said since it is difficult to remember everything verbatim. Put quotes around verbatim statements from the client. Use wording like, “client reported” or “client stated.”
The objective is the facts and includes what the therapist observes. This might include the client’s appearance, affect, mental state, behavior, nature of the relationship, participation and response to the therapeutic process. It can also include outside information like other therapist reports, medical records or psychological tests. When writing the objective part, try to avoid negative terms which can appear as judgements and opinions. Instead of saying “client was drunk”, try pointing out the behavior like “client was slurring their words, smelled of alcohol and stumbled.” Use definitive wording like, “counselor observed”, “client was (blank)” or “client did (blank).” Avoid wording like “client seemed” or “client appeared” unless it is followed by “as evidenced by.” This way you are backing up what you think you are seeing.
The assessment is a summary of the therapist’s clinical thinking about the subjective and objective. It is an analysis of the subjective and objective sections. It can be the most important part of the note and is most likely to be read by others in an audit. It can include information about diagnosis from the DSM 5. It can include clinical impressions that determine differential diagnosis. The assessment can include the therapist’s thinking and reasoning for reaching one diagnosis and not another. It can include the therapist’s interventions and the reasoning for using certain interventions. Use wording like, “as evidenced by” to write why you came to certain conclusions or chose a diagnosis. Use wording like “counselor believes,” “counselor came to conclusion based on (blank) observations” or “counselor suspects” to describe your assessment of what is going on with the client. Use wording like, “counselor believes client could benefit from (blank) technique” or “technique was used because client (blank)” to explain techniques used.
The plan is the action part of the note. It can include the next appointment date, treatment progress, prognosis, intervention actions, homework, psycho-educational materials used, any changes to the treatment plan and treatment direction for the next session. It can be about the client’s goals and objectives that were addressed in the session. It can include any referrals or other treatment team coordination like a consultation with a colleague. The plan should be based on the assessment. For example, you wouldn’t assess that the client could benefit from changing their irrational thoughts and yet the plan is to journal only about their feelings. There needs to be a connection between the assessment and the plan. It can also include the prognosis based on the client’s diagnosis, resources and motivation to change. Prognosis might be stated in terms of “poor, guarded, fair, good or excellent” and the therapist’s reasoning for the prognosis.
D.A.P. notes are similar to S.O.A.P. notes. They include all the same information. They are just organized a little different. D.A.P. stands for data, assessment and plan. The data section includes the subjective and objective data which are separated in a S.O.A.P. note. The assessment and plan sections are the same as in a S.O.A.P. note.