Therapists document information such as cogent psychosocial data, patient progress or regression, treatment modalities, treatment plan modifications and issues involving consent for treatment in psychotherapy progress notes, explains the California Association of Marriage and Family Therapists. Therapists also record details such as dates and types of services, consultation details, assessments and testing reports, according to the American Psychological Association. In general, psychotherapy progress notes detail the what, who and when of treatment.
Therapists also use psychotherapy progress notes to document their opinions of patients' symptoms or diagnosis and track patients’ compliance to recommended treatment regimens, reports the California Association of Marriage and Family Therapists. In addition, therapists use these documents to record safety issues such as the risk of self-harm or child abuse, detail collaborations with other professionals and lay out reasons for terminations and referrals.
While no psychotherapy progress note-taking method is universally suited to all therapists, the SOAP format provides professionals with a convenient framework for clarifying and organizing their thoughts, suggests the California Association of Marriage and Family Therapists. The format consists of four sections: subjective, which is the patient’s self-reported perspective of his problems; objective, which is the therapist’s impressions; assessment, which is the therapist’s analysis of information in the first two subsections; and plan, which details the recommended treatment regimen.