What is a mental health progress note?

Progress notes are a form of documentation mental health practitioners use to record psychotherapy patients’ progress.

Typically, a progress note includes patient-reported and therapist-observed information about thoughts, feelings, and behaviors; analysis or assessment by the therapist; interventions or psychotherapy techniques used in the session; and a plan for what will happen before the next session and in the next session.

Is there consensus on what a progress note needs?

There is overlap among what schools of psychotherapy, licensing boards, agencies, counseling centers, and private practices recommend or require, but there is no single universal consensus. Your location, profession, model, and work setting may determine what is critical.

Three common formats can cover what many insurance carriers, agencies, licensing boards, counseling centers, and private practices want included: BIRP, DAP, and SOAP.

BIRP notes

BIRP stands for Behavior, Intervention, Response, and Plan.

Behavior can include subjective and objective data: what the client reported, what the therapist observed, thoughts, feelings, and overt behaviors.

Intervention describes what the therapist did in session to address symptoms or treatment goals. Techniques could include cognitive rehearsal, mindfulness exercises, relaxation training, exposure, or assertiveness training.

Response documents how the client responded to interventions and interactions during the session, including motivation, alliance, resistance, or repair.

Plan includes what will occur between sessions and what will take place in the next or future sessions, such as homework, referrals, or agenda items.

DAP and SOAP notes

DAP stands for Data, Assessment, and Plan. Data includes subjective and objective information from the client, therapist, questionnaires, or collateral sources. Assessment documents the therapist’s analysis. Plan follows from that assessment.

SOAP stands for Subjective, Objective, Assessment, and Plan. It separates subjective information from objective observations and measures, while Assessment and Plan function similarly to DAP.

Seven evidence-based elements

If your goal is to provide evidence-based care, there are seven items you may want to include in a progress note.

  1. Collaboratively set an agenda.

  2. Review homework or between-session work.

  3. Look at and discuss routine outcome measures or other progress metrics.

  4. Record symptoms, signs, and relevant client reports.

  5. Review the case conceptualization and treatment plan, revising them when needed.

  6. Select the most effective evidence-based technique based on the updated conceptualization and plan.

  7. Discuss what work could be done before the next session to reduce suffering, enhance strengths, improve relationships, increase self-efficacy, strengthen social support, or improve motivation.

Doing all of that in a standard therapy hour is difficult. Recording it can be even harder. My Best Practice helps by automating what can be automated, collecting information, cueing clinicians, and supporting customizable progress notes so therapists can focus on clients.