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What is included in mental health progress notes?

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Quick Answer

Progress notes generally describe important topics discussed during a therapy session, particular interventions applied, observations of the status, symptoms and progress of the client, and plans for the next sessions, reports SimplePractice. Progress notes also include information about results of clinical exams, type of treatment and prescription of medications. Therapists use either the Subjective, Objective, Assessment and Plan, or SOAP, format; Data, Assessment and Plan, or DAP, format; or an unstructured format.

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Progress notes demonstrate how a therapist is continually evaluating the client, notes Psych Central. When using the SOAP format, therapists write subjective information during a session under the Subjective category, including their impressions of clients and opinions of the clients regarding the treatment progress.

The Objective section records a client's actions or words that are clearly observable, states Psych Central. The Assessment category includes potential changes or improvements, while the Plan category describes what a therapist and the client intend to do in the subsequent session.

The DAP format combines subjective and objective details under Data and describes information such as the client's emotions and family interactions and the therapist's instructions, explains Psych Central. Another template for writing progress notes is the Problem, Assessment, Intervention and Plan, or PAIP, format, which records a particular problem addressed during a session, along with treatment evaluation, intervention by the therapist and plans for the next sessions.

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