How to Write Easy Progress Notes Using an EHR
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Writing mental health progress notes can be time-consuming for therapists, especially for those who bill insurance. However, it is possible to write easy progress notes using an EHR, which can save you time on administrative tasks so you have more time to spend on the things that are most important to you.
This guide provides an overview on how to write progress notes with an EHR system using customizable templates you can download for free.
What are mental health progress notes?
Whether you bill insurance or not, mental health practitioners are legally and ethically required to record session notes. These progress notes are a therapist's summary of a session with a client.
Clinicians typically record their progress notes in electronic health record (EHR) systems.
Typically, progress notes include:
- The client's mental health status
- The focus of the session
- Any interventions used
- Any relevant notes of discussion
- Any relevant symptoms or risk factors
- Any assessments used or safety plan implemented
How to write progress notes with an EHR system
There are several ways to write client progress notes.
Some clinicians find it convenient to use standard clinical formats for their notes (see examples below), and others prefer to write easy progress notes using an EHR.
There are several benefits to using an EHR for progress notes, including:
- All notes are in a standardized format
- Clinicians can choose from different templates—with pre-filled forms, prompts, easily fillable text fields, and checkboxes
- Notes are more legible in electronic format
- There is less work required to maintain a manual client file
- Electronic files are typically more secure
The following steps outline how to write easy progress notes using an EHR system:
- Upload a template of your preferred note format or choose a template provided by your EHR.
- Complete the note using your chosen template, save it, and sign the record.
- If you’re an associate or pre-licensed, your supervisor will review the note and sign off on it or send it back for editing.
Easy ways to write progress notes
To write easy progress notes using an EHR, clinicians can use several standard formats, including:
DAP notes
A common type of therapy progress note is a DAP note, which stands for Description, Assessment, and Plan. These progress notes can be useful for clinicians looking to document client details in a brief but detailed manner. Check out SimplePractice’s free DAP note template to customize for your practice.
BIRP notes
Another popular structure for writing progress notes is the BIRP note, which stands for Behavior, Intervention, Response, and Plan. These notes can be helpful to track client progress and adjust treatment plans as necessary. Find out more about BIRP notes and check out SimplePractice’s BIRP note template.
SOAP notes
SOAP notes are another format for progress notes—the acronym in SOAP stands for Subjective, Objective, Assessment, and Plan. These SOAP note examples and template can be downloaded and customized for your practice.
Clinicians may also write notes based on their personal style and include sections they deem appropriate or relevant. Billing expert and therapist Barbara Griswold, LMFT, includes notes on symptoms, topics, risks, actions, improvements, and next session. This information can be particularly useful to note in case of an insurance audit.
If using an EHR for therapy progress notes, the system will typically have pre-filled templates to follow—making this task simpler and saving you time.
Examples of progress notes
We’ve included some examples of how to write progress notes with an EHR system below:
Data
Client attended their fourth session for the treatment of depression. They appeared well groomed, maintained eye contact, and reported an improved mood with congruent affect, noting, “I am noticing that I'm feeling much better.” Their PHQ-9 score today was [X]. In session, the clinician and client worked through the client’s notes from DBT self-inquiry homework.
Assessment
The client’s PHQ-9 scores have reduced over the last three sessions, indicating an improvement to their mood from their initial assessment. Client feedback from their homework indicated that they are responding well to DBT interventions and experiencing an improvement to emotional regulation. Brief ASQ screen produced a negative result, indicating the client is low-risk.
Plan
The client’s next session is scheduled for [DAY, MONTH, YEAR] at [XX:XX] via telehealth using SimplePractice EHR. The client will continue to practice self-inquiry activity and report back next session. The clinician reminded the client of the resource list should there be a change to risk status.
Interventions
Discussed triggers and coping strategies worksheet and selected various strategies from a CBT template. Provided psychoeducation on the window of tolerance and provided a handout temperature gauge—notating the clients triggers for them to observe in between sessions.
Clinical observations/objective
Client appeared well groomed, sat upright, oriented, calm with congruent affect, and normal speech. Their insight and judgment were good.
Subjective concerns noted
Client reported feeling tired and anxious, stating “I just can’t seem to relax. I’ve been tossing and turning all night. I’m exhausted.” They reported that their lack of sleep is affecting their ability to do their job, saying they are getting into trouble with their boss for making mistakes, and it feels like they are getting more depressed.
Checklist for writing easy progress notes using an EHR
Whether you’re using a template, a standardized progress note format, or creating your own custom note, you’ll want to include the following information:
- Client’s name, date of birth, current date and time
- Was the session telehealth? Where were the client and clinician located?
- Mental status examination
- Mood
- Affect
- Appearance
- Safety/risk assessment?
- Symptoms
- Changes to medication
- Interventions used (note response to modality)
- CBT
- DBT
- Narrative
- ACT
- Other (specify)
- Progress towards goals (note reduction in symptoms)
- Plans for next session
How SimplePractice streamlines running your practice
SimplePractice is HIPAA-compliant practice management software with everything you need to run your practice built into the platform—from booking and scheduling to insurance and client billing.
If you’ve been considering switching to an EHR system, SimplePractice empowers you to streamline appointment bookings, reminders, and rescheduling and simplify the billing and coding process—so you get more time for the things that matter most to you.
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