Clinical Progress Notes Template

What is a Clinical Progress Notes Template?

Clinical progress notes are important for tracking your patient's or client's progress over time. They consist of multiple entries from different sessions or encounters with your patient and are invaluable for informing clinical decision-making and maintaining well-organized and comprehensive clinical documentation.

This template makes it easy to organize clinical documentation, whether mental health progress notes or therapy progress notes. It is a blank slate with enough structure to keep your notes organized but enough customizability to accommodate whatever note-taking method you prefer.

This resource is a downloadable, interactive PDF that you can either fill out digitally or print out and fill in by hand. The provided template is a framework for standardizing your clinical progress notes, allowing you to reduce the time spent formatting notes and increase the time spent tending to your patients.

How to use this Clinical Progress Notes Template PDF

Using our simple Clinical Progress Notes Template is easy and straightforward. Just follow these easy steps to start taking your clinical progress notes.

Step 1: Fill in the patient details

This is a very important section, and it is crucial to check for spelling errors or alternatives in the patient's name or optional identifier.

Step 2: Add the date and time

Including the date and time in the clinical progress in your note is important for creating a clear picture of your patient's progress. We have included a date and time column for this reason. 

Step 3: Write your clinical progress note entry

Add an update on client progress or the client's response to any therapeutic interventions that you wish to make in the notes column. Try to keep it concise and legible and at a level that can be understood by the healthcare professionals involved who will be sharing these clinical progress notes.

Step 4: Sign the clinical progress note

If you have not already, add your signature at the bottom of the document for legal purposes and for traceability. 

Step 5: Store your progress notes securely

As clinical progress notes serve as part of your patient's medical record, you have a legal obligation to store your clinical progress notes safely and securely under HIPAA. This will also let you access it more easily for future sessions.

Who can use this Clinical Progress Notes Template?

Clinical progress notes can be used by any clinicians who see patients independently on a long-term basis. This might be:

• Clinical psychologists, counselors, and other mental health professionals
• Psychiatrists
• Massage therapists, occupational therapists or physiotherapists
• Nurses and nurse practitioners
• Specialist physicians
• General practitioners 

And many more!

We have kept this template broad enough so it can be used by a wide range of clinicians who write progress notes. Anyone who routinely takes progress notes for their patients can benefit from using our Clinical Progress Notes Template. Additionally, students or trainees in a clinical discipline may find this template useful for developing their progress note-taking skills.

Why is this template useful for clinicians?

This template is useful for different clinicians across various specialties for the following reasons:

Saves time

This template saves you time designing, formatting, and drawing up your own clinical progress notes table. The Clinical Progress Notes Template also helps clinicians track the important updates on their patients using the Date/Time column.

Make sharing simple

Clinicians often have to share their notes with other specialists, healthcare workers, or other third parties, and ensuring their clinical progress notes are clearly set out and readable will help to improve the coordination of care for their patients.

Keep your clinical progress notes organized

Having separate documents for every progress note, regardless of how concise they may be, can lead to losing certain days or losing track of the order of your notes. Depending on your expertise, you can also use this as a starting point for creating your own therapy progress note template.

Tips for writing clinical progress notes

Effective progress notes are crucial in documenting client care and treatment efficacy. They are a vital communication tool among healthcare providers and form an essential part of the client's medical record. Here are some key tips to help you write comprehensive and professional clinical progress notes:

Use a structured format

Consider using the SOAP note format (Subjective, Objective, Assessment, Plan) or a similar structured template used in other progress and therapy notes. This helps organize information consistently and ensures all relevant details are included. For example:

• Subjective: "Client reports increased anxiety in social situations."
• Objective: "Client displayed visible signs of tension, including rapid breathing and fidgeting."
• Assessment: "Symptoms consistent with social anxiety disorder."
• Plan: "Introduce cognitive restructuring techniques in next session."

Be concise and specific

Focus on relevant information and key points. Avoid unnecessary details or subjective language that doesn't contribute to understanding the client's status or treatment progress. For instance, instead of writing "Client seemed upset," try "Client reported feeling frustrated and exhibited a furrowed brow."

Document objective observations

Include clear, factual observations about the client's behavior, mood, and responses during the session. This might include noting the client's participation in group discussions or their ability to engage in therapeutic interventions.

Record treatment interventions

Document specific therapeutic techniques or interventions used during individual therapy sessions or group therapy. For example, "Introduced deep breathing techniques to manage anxiety symptoms" or "Practiced cognitive behavioral strategies to address negative thought patterns."

Note client progress and challenges

Track the client's progress towards treatment goals and any struggles they face. This helps in assessing treatment efficacy and adjusting the treatment plan as needed. For instance, "Client reported successfully using coping skills learned in previous sessions to manage anxiety at work."

Include risk assessments

When relevant, document if a risk assessment was performed, particularly for clients with a history of self-harm or suicidal ideation. Be sure to note any changes in risk level and interventions implemented.