Updated on: July 18, 2025

In today’s fast-paced healthcare environment, clinicians are under immense pressure to balance quality patient care with meticulous documentation. Progress notes play a crucial role in ensuring accurate communication, continuity of care, and compliance. However, writing clear and concise progress notes can be time-consuming.

Even with well-designed progress note templates, many clinicians still find themselves struggling to strike the right balance: taking thorough notes during a session while remaining fully present with their patients. The pace of a busy clinic often means there’s little time between appointments to complete documentation, which can lead to a backlog of unfinished notes by the end of the day.

To help you save time and stay compliant, we’ve curated a collection of Free Progress Note Templates along with expert tips on how AI Medical Scribes like DocScrib can streamline your documentation process.

What Are Progress Notes?

Progress notes are brief but essential clinical records that document a patient’s condition, care provided, and future treatment plan. They ensure smooth communication across healthcare teams and serve as legal and billing evidence.

How Progress Note Templates Are Used in Mental Health Care

In the realm of mental health, progress note templates are invaluable tools for clinicians navigating the ongoing complexities of patient care. Whether you’re managing medication adjustments, documenting counseling sessions, or tracking psychoeducation efforts, these templates help organize and streamline the process.

Consider a typical scenario: A psychiatrist initiates treatment by prescribing an anti-anxiety medication and recommends regular therapy sessions. At each follow-up—often every two weeks—the provider uses a structured template to record key observations, such as the patient’s emotional and cognitive status, their response to therapy and medication, and any emerging concerns that might influence the treatment plan.

By capturing details like mental status examinations, therapy goals, and progress toward symptom relief, these templates ensure nothing crucial is overlooked. They also aid communication across interdisciplinary teams by presenting information in a clear, standardized format—making it easier to deliver collaborative, high-quality care.

Common Clinical Scenarios for Using Progress Note Templates

Progress note templates find their place in a wide variety of clinical situations. Here are a few of the most frequent scenarios where these templates become invaluable for healthcare professionals:

• Primary Care Follow-Ups: When a patient returns for a routine or chronic condition checkup, clinicians use progress note templates to quickly capture updates since the last visit, assess treatment effectiveness, and document new concerns. For instance, a physician monitoring a patient’s blood pressure may include details about lifestyle modifications, medication adjustments, and findings from each follow-up.
• Inpatient Ward Rounds: In hospital settings, daily progress notes keep multidisciplinary teams on the same page regarding a patient’s status. Each discipline—medicine, nursing, allied health—may use its own template to outline the current condition, address any new developments, and flag important follow-up tasks. For example, during ward rounds, the team records medical updates, planned interventions, referrals to specialty services, and discharge planning steps.
• Chronic Disease Management: Effective management of long-term illnesses like diabetes, asthma, or heart failure often requires consistent and focused progress notes. Templates tailored to the specific condition help clinicians systematically address areas such as medication adherence, lifestyle counseling, laboratory results, and risk factor screening.
• Behavioral and Mental Health Care: Therapists, counselors, and psychiatrists rely on progress note templates to track each session’s goals, interventions, medication changes, and risk assessments. Whether evaluating the outcome of cognitive behavioral therapy or documenting medication adjustments for depression, structured templates make it easier to paint a complete clinical picture across multiple appointments.
• Allied Health Interventions: Physical therapists, occupational therapists, dietitians, and social workers all leverage discipline-specific progress note templates. This approach ensures critical information—like mobility progress after orthopedic surgery, nutritional counseling notes, or psychosocial assessments—is consistently documented and easily communicated among providers.

Having a well-designed template for each scenario not only streamlines note-taking but also ensures legal, billing, and care coordination requirements are met efficiently.

Is There a Universal Progress Note Format?

You might be wondering if there’s a gold standard for progress note templates. The truth is, there isn’t a single format universally endorsed by all healthcare providers. While many clinicians rely on popular structures—like the SOAP (Subjective, Objective, Assessment, Plan) note or a mental state exam template—there’s no “one-size-fits-all” recommendation.

Your choice of template should align with your clinical workflow, specialty, and personal documentation style. Whether you gravitate toward SOAP, DAP, BIRP, or another format, what matters most is that your notes are clear, complete, and consistent. Most organizations and providers adapt templates to best suit their patients’ needs and regulatory requirements, giving you the flexibility to select what works best for you.

Why Use Progress Note Templates?

• Saves Time: Ready-to-use templates reduce manual work.
• Ensures Consistency: Standardized format for every patient note.
• Improves Accuracy: Minimizes omissions and errors.
• Enhances Compliance: Meets HIPAA and billing requirements.

Free Downloadable Progress Note Templates

We’ve created easy-to-use progress note templates that you can download, customize, and start using immediately.

Progress Note Writing: Section-by-Section Examples

To offer a practical guide on writing effective progress notes, here’s how each section of the SOAP format looks in action, using common scenarios as examples.

Subjective
How to capture the patient’s voice and concerns:

• The patient states, “I’ve been sleeping better, but I still feel anxious at work.”
• Family members report the patient seems less withdrawn over the past two weeks.

Objective
Documenting measurable observations and assessments:

• Blood pressure: 124/82 mmHg. Temperature: 98.6°F.
• PHQ-9 score reduced from previous 16 to current 12.
• Patient arrived on time, neatly dressed, and maintained good eye contact.
• No abnormal movements or speech noted.

Assessment
Summarizing clinical interpretation and current diagnosis:

• Moderate improvement in depressive symptoms; anxiety persists but at a lower level.
• No side effects from current medication reported.
• Current diagnoses: Major Depressive Disorder, Generalized Anxiety Disorder.

Plan
Laying out next steps and recommendations:

• Continue current dose of sertraline, 100 mg daily.
• Increase frequency of CBT sessions from biweekly to weekly.
• Patient to practice relaxation techniques daily and track progress in a journal.
• Schedule follow-up appointment in four weeks.

These sample statements illustrate effective, concise entries for each section, ensuring your SOAP notes remain clear, comprehensive, and actionable for ongoing care.

2. DAP Note Template (Data, Assessment, Plan)

📥 Download DAP Note Template

3. BIRP Note Template (Behavior, Intervention, Response, Plan)

📥 Download BIRP Note Template

4. PIRP Note Template (Problem, Intervention, Response, Plan)

📥 Download PIRP Note Template

5. IER Note Template (Intervention, Evaluation, Response)

📥 Download IER Note Template

Choosing and Testing the Right Progress Note Template

Finding a progress note template that truly matches your workflow is a bit like picking out the perfect pair of sneakers: comfortable, supportive, and suited to your terrain. Here’s how clinicians can evaluate and trial different templates before settling on a winner.

• Match the Model to Your Practice
  Start by considering which template structures best suit your specialty—be it SOAP, DAP, BIRP, IER, or something custom. The more closely the format fits your clinical area and documentation habits, the smoother your process will be.
• Review a Variety of Examples
  Look through sample templates from reputable sources or peers in your field. Make note of layouts or prompts that feel intuitive (or conversely, headache-inducing).
• Balance Detail with Efficiency
  A stellar template strikes the right balance: thorough enough to capture key clinical details but not so cumbersome that it slows you down mid-session.
• Test Drive and Tweak
  Use the chosen template during actual client sessions. Notice whether it helps you capture what matters—or if you find yourself skipping sections or getting bogged down. Don’t hesitate to make adjustments; sometimes a small tweak (like rearranging sections or adding a field) makes all the difference.
• Check for Customizability
  The best templates are flexible—allowing you to add, remove, or reorder components as your needs evolve.

By thoughtfully trialing templates and making tweaks as needed, clinicians can land on a progress note system that supports both quality care and efficient record-keeping.

How to Use These Free Progress Note Templates

1. 1. Download the Template of your choice.
   2. Customize it based on your clinical setting.
   3. Document Patient Encounters quickly and efficiently.
   4. Consider Automating with AI medical scribe tools like DocScrib for even greater efficiency.

Want to create your own progress note template from scratch?

You have a few flexible options:

• Start with a reference note: Use an existing note as a foundation and transform it into your own reusable template.
• Edit a community template: Find a progress note template that matches your needs and personalize it to fit your workflow.
• Build from scratch: Prefer a blank slate? Create a template tailored to your unique documentation style or specialty.

For more detailed, step-by-step guidance, check out your platform’s help center or user guides—these typically walk you through importing, editing, and saving your own custom templates so you can streamline documentation your way.

Want to see how DocScrib can transform your documentation? Schedule a Free Demo

Tips for Choosing and Getting the Most from Your Template

• Pick the Right Format: Whether you prefer SOAP, DAP, BIRP, or a custom approach, select a template that aligns with your specialty and workflow requirements.
• Review Examples: Browse a few template samples from colleagues or reputable online sources to see what fits your documentation style.
• Balance Detail With Usability: A thorough template is great—unless it slows you down. Make sure your template strikes the right balance between comprehensive information and ease of use.
• Customize as Needed: Don’t be afraid to tweak your template. Adjust fields or prompts so it truly supports your note-taking preferences.
• Test and Refine: Try your template in real sessions. If it doesn’t quite fit, switch it up. The right template should make your documentation faster and higher quality.

Investing a bit of time now to find and fine-tune the ideal progress note template will pay off in smoother sessions and more timely, accurate notes down the line.

What to Leave Out of Progress Notes

• Skip detailed management plans, treatment summaries, or formal assessment results.
• Avoid including full reports or in-depth evaluations—these belong in dedicated templates or report forms.
• If you perform a structured assessment during the session, simply note that it occurred and store the full documentation separately.

Keeping progress notes brief and focused not only saves time, but also ensures each note serves its intended purpose without unnecessary detail.

Frequently Asked Questions (FAQs)

Q1: Are these progress note templates HIPAA compliant? A1: Templates are compliant when used within HIPAA guidelines. For full compliance, we recommend AI solutions like DocScrib.

Q2: Can I customize these templates? A2: Absolutely. All templates are fully editable.

Q3: Do AI medical scribes replace clinicians? A3: No. AI scribes like DocScrib assist clinicians by handling documentation, allowing them to focus more on patient care.

Q4: How much time can I save with AI medical scribes? A4: Clinicians can save up to 2-3 hours daily by automating note-taking.

Conclusion: Streamline Your Documentation Today

Progress notes are essential but time-consuming. With these free progress note templates and the power of AI medical scribes like DocScrib, you can simplify your workflow, improve accuracy, and regain valuable time for patient care.

👉 Download your free templates and schedule a DocScrib demo today!