Client progress notes examples
How to Write Therapy Progress Notes (with Examples)
Article
Published Apr 13, 2022
Table of Contents
1.What are mental health progress notes?2.How to write therapy progress notes3.What should be included in a progress note?4.Sample therapy progress note5.What are some of the different mental health progress note types?6.Are progress notes the same thing as psychotherapy notes?7.How to use therapy progress notes with your EHRThere is no one size fits all method to completing progress notes, and they can be written in a number of ways. As you get to know your clients and their therapeutic needs, you’ll figure out the best method for your practice. But to start, here’s a breakdown of how to write therapy progress notes, and what to include in yours.
What are mental health progress notes?
Mental health progress notes are what clinicians use to document the details of every session, focusing on the client’s condition coming in, as well as what transpired during the clinician’s interaction with the client. Clinicians have a legal and ethical responsibility to document each treatment episode as part of the client’s official medical record. These notes describe any notable symptoms or other relevant factors in the client’s presentation, changes since their last visit, their response to treatment recommendations, and interventions related to their goals, as well as assessment of client risk.
How to write therapy progress notes
There are a lot of different ways you can write progress notes for therapy. Many clinicians find it ideal to utilize electronic health record systems in order to speed up the process by utilizing clickable checkboxes and fillable templates that hit all of the important elements required for documentation. Electronic notes also have the added benefit of being consistently legible, which is a major requirement of progress notes.
Others prefer to have a physical paper note, as they can complete some of it in-session.
However, it is usually not possible to completely and thoroughly finish a progress note while also being attentive to your client, in addition to risking illegible handwriting.
A hybrid approach might involve some handwritten notes to assist you in remembering some key details when you complete an electronic note later. This approach can also consist of incorporating a paper template form, containing sections for relevant information or checklists, that you can scan and attach to an electronic note. The hybrid approach may be particularly helpful for newer clinicians, in order to provide the added benefit of guiding your session, such as remembering to hit on or assess certain areas, so you’re not kicking yourself later for not asking a key question.
To help you learn how to write these notes, we’ve created a therapy progress note template, which you can customize as you need and put to use right away in your practice.
Download our free sample therapy progress note template!
What should be included in therapy progress notes?
So, how do you write a therapy progress note? The elements that need to be included in your progress notes will vary somewhat depending on requirements of your state, licensing board, professional organization, ethical code, the organization where you work, the modality you are using, and insurance company or third party contracts if applicable.
Each of these may require more specific information, so always check through each of these to add to your own format or templates.
In general, all progress notes should include the following:
Demographic/identifying information
- Client’s name, and an identifier like date of birth
- Date of the session, and exact start and end time of the session
- Clinician’s name, and a handwritten or electronic signature
- For telehealth sessions, the location of the session/client
Description of your client’s behavior
- A description of the client’s presentation (their mood, affect, appearance, and behavior in the session), as well as relevant symptoms that are reported by the client and observed by the clinician
- A diagnosis
- A safety assessment.
While some clinicians do this as needed if a client reports suicidal ideation or self-harm behavior, if you work with high risk clients you may want to document that you checked on this in each session, and that a client denied these, as a safeguard. - Any additions or changes to medications that may impact the client’s mood or symptoms, or a statement about medication compliance or noncompliance for any client who is already taking medications
Treatment plans going forward
- What you did as a clinician (treatment modalities used, what you recommended, what you asked, what you prompted the client to consider, coping skills you taught, handouts or assignments you provided)
- The client’s response to interventions listed above
- The client’s progress toward established goals, in a more specific and short-term format than in their treatment plan, and whether any changes need to be made to the treatment plan
- The plan for the client following the session (what the client will work on, what will be discussed in the next session, when the next session is scheduled)
In addition to these elements, it’s important to keep in mind that progress notes should be primarily objective in nature, and completed with maintaining a client’s privacy in mind.
Progress notes are part of the documentation that could be requested by your client, or subpoenaed and read out loud in a court of law. Does a jury, a client’s soon to be ex-husband, need to hear the contents of your client’s sexual dream, the identifying information of another individual in their life, or your personal opinion about the childhood root of your client’s issue? Most likely not.
Client progress note example
Here’s an example of how some of these elements might be written in your progress note:
Clinician Name
Agency Name
1234 Office Address
Wherever, UR 12345
Client Name: Johnny Appleseed
Client DOB: 01/02/3456
Diagnosis: F 33.0, Major Depressive Disorder, Recurrent, Mild
Date: 03/04/5678
Start Time: 07:03 pm
End Time: 07:58 pm
Client’s Subjective Concerns/Chief Complaint: “I’m starting to feel more depressed.” Client noted concerns about his mood, endorsing depressed mood, lethargy, insomnia, loss of energy and motivation, and urges to isolate from his romantic partner.
Clinical Observations: Client appeared disheveled, which is unusual for him, and a marked change since last session. Client sat in a hunched position upon the beginning of the session, and appeared tired, with slowed movements and dysthymic mood. He was attentive and cooperative, and had congruent and appropriate affect. Client denies suicidal ideation.
Issues and Stressors Discussed/Session Description: Client discussed experiencing increased difficulty with depressive symptoms beginning last week, following an argument with his romantic partner. Client reviewed the details of the argument, and stated that it occurred late on Tuesday night, causing him to get only 4 hours of sleep. Client has continued to attend work, and reports compliance with prescribed medication. Client stated that the argument is now resolved, and he has been communicating with his partner, though he has had thoughts such as “What’s the point? He doesn’t understand me.” Upon further exploration, this writer learned that, since Tuesday night, the client has been spending more time than usual on his mobile device at night, continuing to get a less than ideal amount of sleep (5-6 hours), and negatively impacting his energy level and mood.
While the client did roll his eyes upon this writer bringing up his mobile phone use, he then laughed and stated, “I know, I know, I’m doing it to myself.”
Interventions/Methods Provided: Discussion of symptoms, supportive counseling, identification and exploration of emotions, Psychoeducation: Dialectical Behavior Therapy Emotion Regulation skills, discussion of vulnerabilities, ABC PLEASE handout provided. Review of client’s safety plan.
Assessment: While client’s endorsed symptoms and presentation are in keeping with depression, but are part of a sudden change prompted by an argument and reduction in sleep, it is likely that client’s emotional reaction to the argument with his partner and subsequent poor sleep hygiene are responsible for this sudden shift in mood and appearance. Client does not appear to be at risk of suicide at this time, discussing the importance of being available for his younger brother and pet dog, and is agreeable to following the steps outlined in his safety plan if symptoms increase or ideation occurs.
However, the client is at risk for worsening depression if he is unable to prevent further decompensation.
Plan: Client has committed to resuming a sleep schedule, beginning tonight, and agreed to turn off his smartphone an hour before the established 11PM bedtime. Client will monitor his symptoms, and reach out to this writer if symptoms increase. If symptoms worsen by the next session, this writer may encourage the client to outreach his psychiatrist for an earlier appointment, as their next follow up is not scheduled for another month.
Next Appointment: 03/11/5678
Clinician Signature: ____________________________________
Clinician Printed Name, LCSW
What are some of the different mental health progress note types?
There are several widely used formats for progress notes that can provide a template for making your note-keeping more efficient, while including all of the necessary key points:
- DAP (Description, Assessment, Plan)
- BIRP (Behavior, Intervention, Response, Plan)
- SOAP (Subjective, Objective, Assessment, Plan)
Each kind of note template is similar, but there are some differences that might lead you to choose one format over another.
For example, since SOAP notes were created for healthcare settings, some may find that they prefer DAP notes, which allow for a bit more subjectivity around the elements of mental health that are less black and white. Conversely, some clinicians can easily veer off-course with an open-ended description section like in the DAP note, preferring the more concrete objective or behavioral categories in the SOAP or BIRP notes.
Both SOAP and DAP notes contain an assessment section, unlike BIRP notes, which focus on the response to the in-session interventions, but not the overall condition of the client. Since this type of assessment may be required, particularly for health insurance companies or if you are in a setting that requires you to justify the need for more treatment on a regular basis, many clinicians opt for the SOAP or DAP formats.
Ultimately, you might consider your strengths and difficulties as a note taker. If your notes tend to be lengthy without guidance, or you easily find yourself getting lost in the details and including too much personal client information or subjective opinion, choose a format that helps you to be more succinct, like SOAP or DAP notes.
If these formats cause you to feel boxed in, you might prefer to create your own template that includes all of the factors required, without having to fit them into the categories of any of these formats.
Are progress notes the same thing as psychotherapy notes?
You may have also heard about psychotherapy notes, and it’s important to note that these aren’t the same as progress notes. Psychotherapy notes are private notes, kept separate from the client’s medical record or chart, that are for the clinician’s eyes only. Psychotherapy notes cannot be subpoenaed and aren’t part of the record that gets shared with the client or other providers. This option is helpful to keep in mind when you want to remember some personal details the client shared, a direction you’re thinking of moving in treatment, or some internal experiencing to discuss with your clinical supervisor—but the information would be inappropriate to place in the client’s progress note.
For those clinicians that want a way to document a lot of detail, and have recognized they are likely sharing too much in the description section of their DAP progress note, psychotherapy notes are a great solution as an addendum to the progress note.
How to use therapy progress notes with your EHR
There are several ways you can incorporate digital notes with your EHR. You can either upload a template, or follow the structure within your software. A top-rated EHR will have a dedicated section for notes and documentation, as well as easy-to-use templates that are built right into the platform.
If you’re looking for a fully integrated EHR that works for behavioral health practitioners like you, try SimplePractice for a free 30 days. SimplePractice makes it easy to streamline your notes and documentation, while also improving your clients’ experience.
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How to Write DAP Notes (with Examples)
Article
Published Feb 16, 2022
Table of Contents
1.
What is a DAP note?2.What’s the difference between SOAP notes and DAP notes?3.How long should a DAP note be?4.How to write a DAP note5.DAP notes therapy example6.How to use DAP notes with your EHRThere are many different formats and structures available for psychotherapy and counseling progress notes. One of those formats is DAP notes. Bear in mind that the requirements for documentation vary by clinician, clientele, and a number of other factors. Simply put, there’s no single right way to do documentation, but your documentation format and content should be aligned to your specific practice and needs.
What is a DAP note?
A DAP note is one of the most popular and current ways to write a psychotherapy or progress note. So what is a DAP note? DAP stands for Data, Assessment, and Plan, and is used by counselors and psychotherapists everywhere. DAP notes provide a standardized way to document your sessions and follow the D-A-P format every time.
This note structure also helps clinicians develop documentation that is both brief and complete. Done well, each section should make good logical sense based on the information in previous sections.
Download our Free DAP Note template!
What’s the difference between SOAP notes and DAP notes?
The main difference between SOAP notes and DAP notes is the last section. If you’re familiar with the SOAP note structure, DAP notes are very similar. DAP notes take the Subjective and Objective sections of a SOAP note and combine them into a single section: data.
How long should a DAP note be?
There’s no rule for exactly how long DAP notes should be. The note length depends on a lot of factors, and it’ll vary based on your individual client and the treatment plan you come up with together.
As a guideline though, DAP notes can be shorter when the client is making routine, expected progress.
This can be toward treatment goals, if they present low risk for suicide or other violence, and if there are no changes to their diagnosis or treatment. Longer notes typically are the result of a client not making expected progress, if their symptoms change, if they present heightened risk, or when changes appear necessary to the diagnosis or treatment plan.
How to write a DAP note
When you write a DAP note, it will always follow the same format no matter who your client is. However, the content that’s included in each section of the DAP note can vary based on a number of factors. We’ll go through what each section of a DAP note should include, and how they would be applied with an example.
D – Data
This section is where you add data from your counseling or psychotherapy session. This could include:
- Reason for the visit
- Client presentation/appearance
- Client mental status
- Client reports of current symptoms or important events since the last session
- Results of screening or other measures
- Interventions applied in session
- Client responses to interventions applied
It’s important to note that this section should be limited to information, not interpretation.
Speak factually, and if appropriate, use direct quotes.
A – Assessment
This section is where you take the data from the first section and apply your clinical judgment to it. This could include:
- How the client is progressing
- How the client’s status relates to their treatment goals
- How the client responded
- Changes to the client’s diagnosis
Every note typically includes some evaluation of risk in this section, to ensure that potential indicators of suicide or other forms of risk have been assessed and the clinician has responded appropriately.
All conclusions in this section should be clearly supported by the data in the first part of the note. In fact, when the Data section is done well, the Assessment section will read to clinicians as obvious conclusions based on that Data.
P – Plan
Given the observed data and your interpretation of it, where does treatment go from here? This section could include:
- The date, time, and location of the next scheduled session
- Homework assigned to the client
- Referrals provided to the client
- Consultation or other third-party contact planned by the clinician
- Changes to the treatment plan based on the client’s progress so far
- Additional steps related to the treatment that the client or clinician is expected to take
Related How to Pick a Therapy Notes and Billing Software
DAP notes therapy example
We’ve created DAP note example to help give each section more context.
DAP note example for depression
D- Data
Client reported on time for a third session of CBT to address symptoms of depression. Client was well-groomed and fully oriented. The client reported feeling “a little bit better here and there” since the last session, and noted that they have had an easier time getting to sleep at night. Client also noted recent financial stressors. The client scored a 14 on the BDI-II, scoring in the moderate range. In session, challenged the client’s automatic negative thoughts around their work performance and relationship functioning. Client reported feeling increasingly agitated but understanding that this was “part of the work.” When offered the opportunity to stop the intervention, the client asked instead to continue. Client neither displayed nor reported any other current risk factors for suicide or violence.
A – Assessment
Client reports of reduced sleep symptoms and improved mood, and their improved score on the BDI-II relative to initial assessment, suggest improvement toward treatment goal of reducing depressive symptoms below diagnostic threshold.
Client responded well overall to interventions, and appears to be well-motivated to continue. Client appears to demonstrate low risk level for suicide or violence; the safety plan established with the client at the first session remains in effect.
P – Plan
Our next session is scheduled for Thursday, March 17 at 10:00 am via telehealth. Assigned the client a thought record chart to specifically log instances of automatic negative thoughts regarding relationship functioning. Provided the client with referrals to three potential financial advisors to address reported recent financial stressors. No changes indicated to the treatment plan. Client to follow steps of established safety plan if symptoms significantly worsen prior to the next scheduled session.
How to use DAP notes with your EHR
Now that you have an understanding of the question “what is a dap note,” it’s time to explore how to put them to use in your practice.
To use DAP notes with your EHR, you can either upload a template, or follow the note structure within your software. A top-rated EHR will have a dedicated section for notes and documentation, as well as easy-to-use templates that are built right into the platform.
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Notion. What is it, how to use it and why everyone loves it so much - Services on vc.ru
Notion is a relatively new service for creating notes and text documents, to-do lists, databases, spreadsheets, kanban boards, knowledge bases, project management and collaboration. Investors value Notion Labs at $2 billion
293,488 views
- What is Notion
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- Useful links for users
What is Notion
Notion combines everything you need and allows you not to jump between tabs with a bunch of open services, but to have everything you need in one place.
Notion can replace Google Doc, Evernote, Trello, Todoist and many other services.
Content in Notion consists of blocks that can be moved and easily transformed. Previously, only 1000 blocks could be created for free. But in May 2020, the service lifted this restriction. nine0027 There seems to be no reason not to use Notion now.
What can be done in Notion
The more you use Notion, the more you find different features and options for using the service.
Personal use
Notion's scope for personal use is enormous. You can use it as a service for taking notes, making a to-do list, keeping a personal diary or habit tracker, organizing household chores, or keeping a list of goals for the year. nine0003
I also write this article first in Notion - it is very convenient to swap blocks, edit titles and mark with tasks what else I want to add and where.
Evgeny Egorov organized a whole system of introspection and self-development in Notion. You can read about exactly how he did it here.
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Knowledge Base
Create your own little Wikipedia with personalized filters and navigation. Great replacement for Linked Note, Confluence and GitBook. You can design it for yourself, share it with colleagues, or even put it in the public domain (it will turn out almost an online course).
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nine0002 And this is what Nikita Larionov's productivity course looks like from the inside, which he also designed in Notion.
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And tables with some can replace CRM for you or even become an analogue of Excel and Google Sheets.
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https://www.youtube.com/watc? v=WojlMBcd404 - Notion training webinar for beginners in Russian.
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LinkedIn Connection Message Templates We are going to show you that depending on your use case, we can give you a concrete example of why this works and how to set it up. Of course, you can (and we advise you) use one of the automation programs available on the market.
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LinkedIn Group Member Connection Request
If that person is active in the group , posted a post, or commented on a post, you can very well use this template 😊 to request a connection.
Copy/paste template
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Hi John, I've seen you work with animals and losing your feline friend can be a disaster.
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This post mostly appears when you're new to LinkedIn 🌱 and don't have a real strategy for getting attention and/or searching. If your goal is simply to get visibility on your posts to expand your network, you can use this search post and expand your network. nine0003 Copy/Paste Template Hi Mikael, I'm new to LinkedIn and I see we have a few common topics like {{commontopic}}. Waalaxy example Why does it work? You can definitely use this template because it will show the person that: alumni or teacher Copy/paste the template Hello Stephanie, I see that you are doing well in your new job and that my topic did not make you sweat! What would you say if we add each other as friends to discuss your activities and remember your school days? nine0003 Waalaxy example Why does this work? The reasons why this type of invitation works are as follows: When you are a recruiter you can sometimes forget that a candidate has a choice. If you want to hire that special gem 🦪, you need to know how to talk to them and submit a connection request. Copy/paste template Hello {{firstname}}, I see that you are looking for a job in {{sectorsought}}. Our company {{companyname}} is looking for {{jobname}}. If you are interested, we can discuss this in a future interview. nine0003 Waalaxy example Why does this work? This approach works because: Perhaps you have worked with someone in the past and would like them to remember you in a future project ? Here is the place where you can do it 👇. Copy and paste the template Hello Sarah I was happy to be able to contribute to the {{projectname}} project and see how well it develops. I would like to add you to see his progress and why not collaborate again on a new project. I look forward to an exchange of views. nine0003 Waalaxy example Why does this work? When the relationship with client goes well, it is recommended to add him to LinkedIn, and he will definitely accept you, because : Your teaser message is also the time to anchor the step when you are about to write an invite to someone on LinkedIn you met at the event . Copy and paste template Hello David It was a pleasure to meet you at the climate conference on {{date}}. I especially liked your presentation. I was very inspired by our exchange of views on human issues. Maybe we could exchange some more views on this topic on LinkedIn? nine0003 Waalax example Why does it work? This message template works because: There are times when you need to submit a application through LinkedIn. It's possible, provided you do it right. Copy/paste template Mr/Madam {{surname}}, I read about your {{companyname}} and see that you are looking for a data analyst. Perhaps we could consider discussing your recruiting? I will be very grateful if you join my network. Looking forward to your messages. nine0003 Waalaxy example Why does it work? This connection request message type works because: Connecting with someone is not rocket science 🪄 and it's even easier if you have someone you know in a mutual connection. Here is a LinkedIn message template to use when you have a mutual friend. Copy/paste template Hello Gerald I see you knew Stefan. We work in the same industry and have worked together many times. I see that you are also working in the same field. We could exchange views on this topic, what do you think? nine0003 Waalaxy example Why does it work? This pattern works because: When you make a connection request on LinkedIn, you want that person to accept you. And sometimes you run into people who write well, especially articles and posts in LinkedIn . Copy and paste the template Hello {{firstsname}}, I was lucky enough to stumble upon one of your articles and found it fascinating and very inspiring! However, I have a question regarding {{subjecttheme}}. I would be glad if you join my network so that I can better understand this issue. Hope to see you soon. nine0003 Waalaxy example Why does this work? This model is great because: You have finally decided to start selling a product or service. You're talking about it on LinkedIn, and all of a sudden one of the potential customers of asks you a question in the comments? It's time to add it to your network. Copy/paste template Hello {{firstname}}, I noticed your interest in my last post. Your question seems very relevant to me, and I would like to discuss it with you, if you don't mind. To do this, I would like you to join my network. nine0003 Waalaxy example Why does it work? Appeal to potential partner must be clear so that he wants to cooperate with you. Copy/Paste Model Hello Joan, I'm very impressed with your technical expertise. You talk about it with great pedagogy. I have actually followed some of your guides and my height is really on the rise. I would like to talk to you about a project that might be of interest to you. Why don't you join my network? nine0003 Waalaxy example Why does it work? This model works because: You will notice that our templates are relatively short. We are trying, in fact, to the maximum to attract the attention of readers among the first lines of the conversation with the goal. But first of all, how do you invite someone to LinkedIn? We will show you an extremely simple instruction: If we talk about this topic, it is because it comes up often. If we only look at statistics (because we ran several LinkedIn campaigns with Waalaxy) , we will see that out of 2000 invitations: But you must understand that this is a statistical reality. You can refer 👉 to this article to understand. Be sure to look at the global picture. First of all, you need to consider the following: Absolutely! If you answered “no” to these questions, then chances are that your invitation will not be accepted. On the other hand, if you're not very confident with your copywriting, send invitations without a note. On the other hand, if you have done a good job of segmenting audience , if you managed to captivate her from the first lines of your message, then you should leave invitations with a note. If you see your prospect's acceptance rate getting better when you add a rating, then you're on the right track. This article is coming to an end and we have shown you various message templates to connect with someone. As a reminder, according to our research, it's best not to send a note when you send a connection request to someone... In theory. Yes, because it is when you have bad copywriting , when you don't know how to talk to your target, that you are most likely to get rejected. If you absolutely want to send a message to your potential client, you can first send him an invitation without any notes, and then send him a message in which you can talk about your product, service 💰 or a topic that is important to you. nine0003 So we've seen how to send a connection message using one of the automation programs that you know well - Waalaxy: We also saw how to make a request for connection to LinkedIn using the tutorial. In this article about LinkedIn Connect Message Templates, we looked at several LinkedIn invitation templates. nine0003 There is no one-size-fits-all message for all LinkedIn connection situations (otherwise it would be too simple and, most importantly, would not be such a personalized ). However, before you start sending out messages to establish connections and expand your network, you need to go through several important steps, such as determining your persona and optimizing your profile. Whether you're in the LinkedIn network for the purpose of searching for , increasing your visibility 👀 or just to find out about new opportunities, you need to be sure to define your ideal goal, we're talking about your persona. Yes, you will have to wait a bit before sending your very first message. If you are selling a particular product or service, this is a very important step you must take. We are talking about your target audience. If you don't know the person most likely to buy your product, then chances are you won't sell anything. Think about personas and segmentation. nine0003 Super Jamie, but how do you create a good persona ? We will explain it to you right now. You will need: Before you start searching on LinkedIn, posting LinkedIn connections, and before you send messages, you need to optimize your LinkedIn profile to impress . We mean you need to take care of..: Optimization goal ✨ of your profile will help you with branding . We don't specify it, but watch out for spelling when writing. It looks more professional and contributes to your image . If you want to get a full course on this subject, we advise you to read this article. You should also remember to update your profile as soon as it changes.
So I would like to join your network, what do you say?
#4 LinkedIn message template for
You can totally engage people you knew through school (this also works with a former colleague).
#5 LinkedIn recruiter communication message
#6 LinkedIn Connection Request: Client Connection
#7 LinkedIn teaser message: Add someone you met at the event
#8 LinkedIn Connection Message Templates : Job Application
#9 LinkedIn connection: You have a mutual connection
#10 LinkedIn Outreach Message : Add author of article or post
#11 LinkedIn networking Messages: Connect with a potential buyer who is interested in your product or service
#12 Connect requests LinkedIn: Partnership
How do you make a connection request?
LinkedIn Connection Message Template : With or without a note?
If you want to know what works best for you ❤️, experiment and do A/B testing. Article Conclusion:
LinkedIn Connection Message Templates: 12 Examples to Shine
FAQs Article : LinkedIn Connect Message Templates
Prerequisites before running prompts
Persona
LinkedIn Connection Message Template: Optimize Your LinkedIn Profile
LinkedIn Connection Message Templates : What to say in a LinkedIn message?
If your copywriting is top notch, then you should definitely send LinkedIn messages to potential leads when you request links on LinkedIn.
The main thing is personalization and the ability to spark the curiosity of your potential client or reader. Remember that you will only have one chance to make your first impression amazing. nine0003
When you add personalization to your connection request, you will be able to start a really impressive conversation (feel free to customize it) with this person. But be brief and try to capture the other person's attention in the first two lines.
LinkedIn Connection Message Templates : Best LinkedIn Communication Message
There is no perfect message on LinkedIn, no perfect connection request. It depends on many factors such as:
- Your target on LinkedIn.
- What are your goals on LinkedIn.
- What do you really want to achieve on LinkedIn.
Also, depending on your search funnel, you won't be sending the same message over and over. However, there are rules to follow when you want to address someone, such as:
- Politeness (it goes without saying, but we like to keep it in mind).
