Types of Progress Notes: How DocScrib Helps Clinicians Document Smarter

Updated on: September 15, 2025

In healthcare, progress notes are one of the most essential forms of documentation. They serve as a daily log of a patient’s condition, treatment plan, and overall progress. Beyond patient care, they also support compliance, billing, and team communication.

Yet, not all progress notes are the same. Clinicians use different types of progress notes depending on the setting, specialty, and encounter. Knowing which format to use—and how to streamline documentation—can make a huge difference in efficiency and accuracy.

That’s where tools like the DocScrib AI Scribe come in. With Docscrib, clinicians can generate structured, accurate progress notes in real time, directly inside their EHR.

👉 Discover Docscrib

What Are Progress Notes?

Progress notes are clinical records written by healthcare providers to document a patient’s medical status, treatment response, and updates to the care plan. They are critical for:

• Tracking Patient Progress → Over days, weeks, or months of treatment

• Facilitating Team Collaboration → Allowing multiple providers to stay aligned

• Ensuring Billing Compliance → Supporting claims with ICD-10 aligned documentation

• Legal & Audit Purposes → Serving as verifiable records of patient encounters

Types of Progress Notes Commonly Used in Healthcare

1. SOAP Notes

Subjective, Objective, Assessment, Plan (SOAP) notes are the most widely used format. They provide structure while still allowing clinicians to capture the patient’s story.

• Subjective → Patient-reported symptoms and history

• Objective → Clinician’s observations, vitals, test results

• Assessment → Diagnosis and interpretation

• Plan → Next steps, treatment, and follow-up

👉 Related reading: How SOAP Notes Improve Documentation

2. DAP Notes

Data, Assessment, Plan (DAP) notes are a simplified alternative to SOAP. Often used in behavioral health, DAP focuses on clarity and brevity.

• Data → Observations and patient statements

• Assessment → Clinical interpretation of the data

• Plan → Treatment recommendations and next steps

3. BIRP Notes

Behavior, Intervention, Response, Plan (BIRP) notes are popular in psychiatry and mental health settings.

• Behavior → What the patient did or reported

• Intervention → Actions taken by the clinician

• Response → How the patient reacted

• Plan → Ongoing care and follow-up

👉 Explore more structured note formats on our Docsib Blog.

4. GIRP Notes

Goal, Intervention, Response, Plan (GIRP) notes emphasize measurable outcomes and patient goals—especially valuable in therapy and rehabilitation.

• Goal → The desired health or behavioral outcome

• Intervention → Steps taken toward achieving the goal

• Response → Patient’s reaction and progress

• Plan → Adjustments or continuation of care

5. Narrative Notes

These are less structured, free-form notes where clinicians document in their own words. While they allow for storytelling, they can lack the consistency needed for compliance and billing.

6. POMR Notes

Problem-Oriented Medical Records (POMR) are organized by medical problems and treatment episodes, often used in multi-specialty settings.

• Problem list

• Data base

• Care plan

• Progress notes linked to specific problems

Why the Right Note Type Matters

Choosing the right progress note type ensures:

• Consistency → Improves clarity across the care team

• Compliance → Supports ICD-10 coding and billing requirements

• Efficiency → Saves time and reduces documentation errors

• Better Patient Outcomes → Enhances continuity of care

How DocScrib Simplifies Progress Notes

With DocScrib AI Scribe, clinicians don’t need to worry about formatting. The system automatically generates structured notes in the clinician’s preferred format:

• SOAP, DAP, BIRP, GIRP, Narrative, or POMR

• Specialty-specific adaptations (psychiatry, orthopedics, pediatrics, cardiology, etc.)

• ICD-10 aligned documentation for billing compliance

• Secure, HIPAA & GDPR compliant storage

👉 Learn more about how Docscrib supports clinicians.

Progress Notes for Clinicians Include Docscrib: Key Benefits

For Clinicians

• Personalised notes written in their style

• Reduced after-hours documentation (“pajama time”)

• More time for patients, less for paperwork

For Hospitals

• Higher accuracy and compliance

• Improved claim acceptance rates

• Centralized team access to patient records

For Consultants

• Easy-to-review, structured progress notes

• ICD-10 ready for audit and billing

• Better oversight across cases

How to Get Started with DocScrib Progress Notes

1. Book a Demo → Schedule Your Demo Here

2. Integrate with Your EHR → Minimal setup required.

3. Choose Your Note Style → SOAP, DAP, BIRP, GIRP, Narrative, or POMR.

4. Go Live → Experience faster, smarter documentation with Docscrib.

FAQs

Q1: Which type of progress note should I use?
It depends on your specialty—SOAP and DAP are most common, while BIRP and GIRP are popular in behavioral health.

Q2: Can Docscrib adapt to my specialty’s documentation style?
Yes. Docscrib supports multiple note formats tailored for psychiatry, orthopedics, cardiology, pediatrics, and more.

Q3: Are Docscrib notes ICD-10 compliant?
Yes. All notes include ICD-10 coding support to ensure billing accuracy.

Q4: Is Docscrib secure for progress notes?
Absolutely. Docscrib is HIPAA & GDPR compliant, with encryption at every level.

Q5: Does Docscrib replace human input?
No—it enhances clinician workflows while leaving final oversight to professionals.

Conclusion: Smarter Progress Notes for Every Clinician

Progress notes are vital to patient care, but they don’t have to be a burden. With the DocScrib AI Scribe, clinicians can generate personalised, structured, ICD-10 aligned progress notes across multiple formats—without wasting hours on manual typing.

The result? Better compliance, stronger collaboration, and more time for patients.

👉 Ready to transform your progress notes? Book a Demo with Docscrib