10 Examples of What Not to Do When Writing Progress Notes

What are progress notes?

Progress notes are essential clinical documentation that provides a detailed record of a client's care journey, therapeutic interventions, and treatment outcomes over time. These notes are the primary method of tracking client progress and maintaining continuity of care across healthcare providers. Unlike basic medical records, progress notes capture objective data and professional observations about the client's condition, responses to treatment, and the client's progress toward established treatment goals.

In mental health settings, mental health progress notes take various formats, including SOAP notes (Subjective, Objective, Assessment, Plan), BIRP notes (Behavior, Intervention, Response, Plan), and DAP notes (Data, Assessment, Plan). Each format provides a structured approach to track client progress, document individual or group therapy sessions, and other clinical interventions. Progress notes must also demonstrate medical necessity to an insurance company while maintaining comprehensive documentation that meets professional and licensing board standards.

10 Examples of What Not to Do When Writing Progress Notes

Mental health professionals can fall into common mistakes and pitfalls when they write progress notes. Here are detailed examples of poorly constructed progress notes. Each example demonstrates common progress notes' examples of errors that can compromise the effectiveness and professionalism of documentation:

Example 1

Sasha feels underappreciated at work, frequently mentioning, "No one acknowledges my efforts, and as soon as I complete tasks, I'm immediately burdened with more without any thanks." She describes a persistent sense of misery and reports frequently feeling low throughout the workday, impacting her overall well-being and job satisfaction.

Issue: This note relies too heavily on direct quotes and subjective feelings without objective analysis or clinical interpretation. It's important to include objective observations and avoid jargon or subjective interpretations that can obscure clear communication.

Example 2

Lisa has been struggling with significant sleep disturbances, stating that she manages to get only about three hours of sleep each night. She also finds herself unable to stop ruminating thoughts at bedtime, exacerbating her inability to sleep.

Issue: The note fails to provide specific details on the severity of insomnia or its impact on Lisa's daily life, which is crucial for formulating an effective treatment plan. Avoid including irrelevant details and focus on concise information directly related to the patient's condition.

Example 3

The client, an enthusiastic knitter, reports that increasing joint pain significantly restricts her ability to engage in knitting, a hobby she finds emotionally fulfilling. This limitation not only frustrates her but also contributes to a sense of loss and emotional distress, as she can no longer participate in an activity she loves.

Issue: The note is informal and lacks detailed objective observations or medical terminology necessary for accurate medical documentation. Utilize clear and professional language to ensure that medical records are understandable to all healthcare professionals involved in the patient's care.

Example 4

Lucas appears visibly anxious during consultations, constantly moving in his seat and unable to stay still. He frequently discusses his increasing difficulty in managing anxious thoughts, which are becoming more intrusive and overwhelming, significantly affecting his ability to focus on daily tasks.

Issue: The description lacks clinical measurements of anxiety and specific symptoms and utilizes a non-professional tone. Clear, concise, and objective language is necessary to convey medical information efficiently.

Example 5

Mia reports a noticeable decline in her vocal strength at work, which has begun to draw attention and make her self-conscious. Despite regularly practicing vocal exercises, she has not observed any improvement, which increases her anxiety about speaking in professional settings and affects her professional performance.

Issue: This progress note lacks objective voice assessment and does not specify the effectiveness of the interventions. Therapy progress notes should avoid cutting corners in descriptions and provide a full account of treatment effectiveness.

Example 6

Following recent treatments, the patient describes a noticeable decrease in cervical pain and an improvement in neck mobility. He specifically notes an enhanced ability to turn his head to the right without discomfort, which marks a significant improvement from his initial condition.

Issue: The note omits detailed treatment effects and medical specifics, reducing its utility for future reference. Comprehensive documentation is vital, especially in high-risk patients.

Example 7

Tom feels that his hard work is consistently overlooked at his job, leading to significant stress and feelings of undervaluation. This perception of being unappreciated contributes to his overall emotional distress and dissatisfaction at work, compounding his stress levels and negatively impacting his mental health.

Issue: The note oversimplifies Tom's emotional distress and does not explore potential underlying issues. Effective notes should thoroughly document the physical and psychological aspects to guide treatment.

Example 8

The patient arrived in severe distress, presenting with acute stomach pain rated at 8/10, and appeared sweaty and flushed during the consultation. His discomfort was palpable, and he had not taken any pain relief before the visit, which left him struggling to communicate his symptoms effectively and in considerable pain.

Issue: The note lacks detailed diagnostic information and rationale for treatment choices, utilizing an overly casual tone that lacks professional detachment. This can lead to confusion and misinterpretation, potentially resulting in misdiagnosis.

Example 9

The patient reports sleep disturbances due to pain in the right shoulder, affecting his daily activities and range of motion. This pain becomes particularly pronounced at night, significantly impacting his quality of sleep and overall quality of life.

Issue: The description is vague and does not include specific clinical findings or the impact of these symptoms on daily life. Documentation should always be detailed and precise to ensure effective ongoing management.

Example 10

Emma reports increasing difficulty standing for long periods due to significant knee pain, which has progressively worsened. This pain severely limits her mobility and affects her ability to engage in routine activities, diminishing her independence and overall quality of life.

Issue: The note fails to provide detailed diagnostic information or a specific treatment plan. It's crucial to avoid shorthand or unclear abbreviations that could lead to misunderstandings or misinterpretations.

Whether you're writing psychotherapy notes or progress in therapy notes, these examples emphasize the importance of clear, objective, and detailed progress notes in supporting effective patient care. It is important for a mental health professional to keep this in mind to enhance communication among other mental health professionals or other healthcare providers.

7 tips for writing professional progress notes

Crafting clear and informative progress notes is essential for documenting a therapy session and providing effective patient care. Here are ten tips to elevate your note-taking skills:

1. Verify patient identity: Double-check patient identification using name and date of birth to ensure you're documenting the correct individual.
2. Use standardized colors: Opt for black or blue ink, as these photocopy well and maintain readability for legal documents. Avoid using colored pens that may hinder legibility.
3. Use legible handwriting: Maintain clear and concise handwriting for straightforward interpretation by other healthcare professionals.
4. Ensure timely documentation: Include the date and time of your notes to ensure an accurate timeline of patient interactions.
5. Ensure proper identification: Sign your notes to identify the healthcare professional who evaluated the patient.
6. Provide accurate corrections: If you make an error, draw a single line through it, then sign and date the correction to maintain document integrity.
7. Use professional language: Utilize professional terminology with proper grammar and spelling. Avoid abbreviations and slang to ensure clarity for all readers.

These practices will create high-quality progress notes that contribute to efficient communication, improved patient care, and a strong foundation for providing quality patient care and for legal defensibility.

Final thoughts

Progress notes are a relatively simple way to begin incorporating into your healthcare practice. However, you must follow essential learning processes to ensure legal compliance and create practical progress notes that can be easily understood. Using structured templates such as our Progress Notes for Mental Health Counselors Template, SOAP Progress Notes Template, or Progress Notes for Nursing Template can help you save time while enhancing your note-taking process.

Carepatron is a comprehensive practice management system that provides clinical tools for healthcare businesses. It can quickly get you started to ensure you don't miss any critical parts of progress notes.

Beyond templates and systems, the true value of progress notes lies in their role as a bridge between sessions, providers, and milestones. When approached thoughtfully, progress notes become more than just documentation. They serve as a vital tool for tracking therapeutic growth, ensuring continuity of care, and maintaining professional accountability.