Step-by-Step Progress Note Template with Examples

Updated on: July 22, 2025

Accurate, concise, and compliant progress notes are essential in healthcare. They document patient status, treatment interventions, and clinical reasoning after each encounter. A structured template saves time, fosters consistency, and ensures communication across care teams—and with DocScrib’s AI Medical Scribe, creating these notes becomes seamless.

📌 What Are Progress Notes?

Progress notes are the formal records clinicians write during inpatient, outpatient, or counseling encounters. They serve to:

• Track patient progress and response to interventions
• Communicate updates to other providers
• Support legal, ethical, and billing standards

These notes are crafted by all members of a multidisciplinary team, often on a daily basis in inpatient settings. For example, in a short stay medical ward, the medical team typically writes a progress note once per day during ward rounds, documenting the current medical status, any changes to treatment, required input from other specialties, follow-up tasks, and discharge planning. Other members of the care team—nursing, allied health, and more—add their own notes, outlining their unique contributions, follow-up needs, and recommendations within the context of the broader management plan.

Some teams may use role-specific templates, such as nursing progress notes or internal medicine templates, while others opt for a more generic structure that clinicians from any discipline can use to record updates and plans.

Common formats include SOAP, DAP, and BIRP, adapted to clinical needs.

🧩 Core Elements of a Quality Progress Note

A strong template should include:

• Date/Time & Clinician ID
• Subjective (S): Patient’s report since last visit
• Objective (O): Vital signs, physical findings, lab results
• Assessment (A): Clinical judgment or status update
• Plan (P): Interventions, education, referrals, follow-up

This structure ensures clarity, continuity, and alignment with treatment goals. It also provides a real-time snapshot for all team members, supporting seamless handovers and collaborative care.

✅ Why Use a Progress Note Template?

• Consistency & Efficiency: Templates reduce documentation time and cognitive load
• Complete Documentation: Prompts inclusion of all crucial information
• Billing & Compliance: Facilitates justification of services and legal requirements
• Improves Continuity: Helps the care team understand progression and future actions

Whether you’re managing daily ward rounds or coordinating multidisciplinary input, using a progress note template ensures every update is captured, every team member is informed, and every patient receives safe, coordinated care.

🛑 Common Challenges in Progress Note Documentation

While structured templates like SOAP and DAP can streamline the process, clinicians often run into a few persistent obstacles when documenting progress notes:

• Balancing thorough documentation with providing undivided attention to patients during sessions
• Finding enough time between back-to-back appointments to complete notes promptly
• Facing end-of-day backlogs when several notes remain unfinished

These challenges can make efficient recordkeeping tricky—even for seasoned professionals—despite the availability of helpful templates and tools.

🚫 What Should Not Be Included in a Progress Note Template?

A well-constructed progress note template keeps things focused and efficient. It’s important to avoid features better suited to other documentation types, such as:

• Full treatment plans: Detailed management or care plans belong in their own designated documents.
• Comprehensive assessment reports: Lengthy diagnostic or psychosocial evaluations should be recorded in dedicated assessment templates.
• Extensive historical summaries: Limit history to what is directly relevant to the current encounter.
• Redundancy: Avoid copying case histories or previous notes verbatim.

In essence, your progress notes should highlight actionable updates from each session—not serve as a storage place for entire care histories or formal reports. If a session includes a significant reassessment or a new comprehensive treatment plan, create a separate assessment or management record and refer to it briefly in your progress note for clarity and continuity.

🛠️ How Clinicians Can Create a Custom Progress Note Template

Designing your own progress note template empowers you to streamline documentation for your practice’s unique needs. Here’s how to get started:

• Start With a Sample or Reference Note
  Review notes you’ve written before—what worked well? Use a prior progress note as a base, and identify the elements you need every time.
• Modify an Existing Template
  Explore widely-used templates like SOAP, DAP, or BIRP. Tweak sections, questions, or prompts so they reflect your workflow, specialty, or patient population.
• Build From Scratch
  Prefer a completely tailored template? List the required sections (date/time, subjective, objective, assessment, plan, and any specialty-specific elements). Arrange these components in an order that matches your documentation style.
• Incorporate Digital Tools
  Many electronic health record (EHR) systems offer template editors, allowing you to drag-and-drop required fields or set up dropdowns and checkboxes for efficiency.
• Test and Refine
  Use your template in practice. Adjust as needed—your goal is clarity, completeness, and minimal redundancy.

A collaborative approach also works well: share drafts with colleagues to gather feedback and ensure compliance with institutional or regulatory requirements. With a little setup, your custom template helps you document smarter, not harder.

📝 Common Progress Note Formats

Most clinicians adapt these to fit practice needs.

🗂️ Examples of Free Progress Note Templates Across Specialties

Looking for progress note templates tailored to specific clinical roles? Here are a few adaptable examples used by providers in various fields:

• Primary Care Follow-Ups
  In primary care, providers routinely document follow-up visits for both acute and chronic conditions. For example, a physician tracking new-onset hypertension will use progress notes to log each step: from the initial discovery and lifestyle recommendations to ongoing monthly check-ins, noting the patient’s response, any adjustments to the plan, and emerging concerns.
• Inpatient Medical Treatment
  Within inpatient settings, progress notes are often completed daily by every member of the multidisciplinary team. A typical short-stay medical ward might see physicians, nurses, and allied health professionals each updating progress notes during ward rounds. These entries detail current status, treatment changes, recommendations, tasks for follow-up, and discharge planning—keeping all team members aligned in real time.
• Chronic Disease Management
  For patients with ongoing needs—such as diabetes or heart failure—progress notes track long-term management. Endocrinologists, for instance, document glycemic control, medication adherence, and specific risks like foot health at each diabetes checkup. Tailored templates help ensure every relevant aspect is reviewed and recorded.
• Mental Health Care
  Behavioral health providers rely heavily on progress notes to chronicle medication management, counseling outcomes, and psychoeducation. For example, a psychiatrist managing anxiety might document changes in mental state, therapeutic response, and any evolving risks during each follow-up.
• Allied Health and Rehabilitation
  Physical therapists, social workers, and other allied health professionals use discipline-specific progress note templates. A physical therapist working with a geriatric patient post-hip fracture may focus on pain, mobility, and function, while a social worker’s note might address support systems and home environment.

Progress notes, regardless of setting, are indispensable for tracking patient journeys, refining treatment plans, and ensuring that every member of the care team is operating with up-to-date, actionable information.

Templates from trusted organizations such as the American Academy of Family Physicians (AAFP), American College of Physicians (ACP), and National Alliance on Mental Illness (NAMI) are widely referenced and free to use for clinical documentation.

🕵️‍♂️ How Clinicians Choose the Best Progress Note Template

Selecting the ideal progress note template isn’t a one-size-fits-all affair. Instead, clinicians typically approach it like a scientific experiment—testing, refining, and adapting until the right fit emerges.

Here’s how the process often unfolds:

• Match Template to Clinical Needs: Start by identifying a format—SOAP, DAP, BIRP, or even a custom hybrid—that accommodates both your specialty and documentation style.
• Review a Range of Examples: It helps to browse examples from peers or reputable organizations. This offers a sense of what’s typical in your field and may spark ideas for must-have features.
• Assess for Practicality: While comprehensive documentation is important, the chosen template should remain practical. If recording notes starts to feel like running a marathon in snow boots, that’s a sign the format may be too complex for daily use.
• Test Drive and Adjust: Many clinicians try out a promising template in a few sessions, then reflect on whether it supports efficient, clear note-taking—or just creates more paperwork headaches. Small tweaks or customization can fine-tune the fit.
• Iterate as Needed: Don’t hesitate to swap to a better-suited template if the first choice falls short. Over time, clinicians often land on a “best-of-both-worlds” system tailored to their workflow.

Ultimately, finding—or creating—a progress note template that matches your rhythm can mean less administrative hassle and better documentation overall.

💼 Sample SOAP Progress Note

**Date**: 06/30/2025 10:00  
**Clinician**: Dr. A

**S**: Patient reports daily headaches of “4/10,” light-focused, improved with rest.

**O**: BP 130/80; PERRLA; neck supple; neurological exam normal; EEG pending.

**A**: Tension-type headaches, chronic; rule out migraine or secondary causes.

**P**: Continue ibuprofen 400 mg PRN; relaxation exercises; neurology referral; follow-up in 2 weeks.

🎥 Watch & Learn: Progress Note Tutorials

Understand templates and note-writing strategies with these insightful videos:

Writing progress notes for any clinical setting – Osmosis (example SOAP/BIRP tips)

Secrets to a three-minute progress note – time-saving strategies

💡 Tips for Faster Notes

1. Prepare template in advance—have SOAP or other sections ready
2. Use bullet points—clear and to the point
3. Capture while interacting—scribe or voice-dictate in real-time
4. Link to treatment goals—connect note to plan and patient objectives
5. Regularly time-block for note review—prevents backlog and improves accuracy

Finding a Progress Notes Template That Works for You

Not all templates are created equal, and your workflow (and sanity) will thank you for picking the right one. Here’s how to get the best fit:

• Choose the best format: Decide which structure (SOAP, DAP, BIRP, or something custom) matches your clinical approach and documentation requirements.
• Check out examples: Browse templates from colleagues or reputable online sources to see what clicks.
• Balance detail with usability: A thorough template is great, but if it’s too complex, it may slow you down. Look for one that feels intuitive and doesn’t bog you down.
• Customize as needed: Don’t be afraid to tweak your template. The best tools are the ones tailored to your style.
• Test and adjust: Try out your chosen template during a few sessions. If it doesn’t streamline your note-taking, swap it out—no guilt necessary.

Spending a little extra time up front to find (or fine-tune) your ideal template can save you hours in the long run and make documentation less of a chore.

🤖 How DocScrib Enhances Progress Notes

With DocScrib’s AI Scribe, you can:

• Voice-dictate the S/O/A/P components during the visit
• Auto-format structured progress notes for EHR export
• Customize templates per encounter type (inpatient, therapy, chronic care)
• Maintain compliance with accurate and timely documentation

Even the best progress note template may require some tweaking, so be sure to check customization options to ensure it fits your specific workflow or clinical specialty. Taking a moment to tailor your templates can make documentation even more efficient and help you capture the details that matter most for each patient encounter.

This streamlines workflows and ensures high-quality, accurate notes every time.

🎯 Final Takeaways

• Progress notes (especially SOAP) are integral for tracking clinical care
• Templates simplify documentation and ensure compliance
• With embedded goals and progress, notes inform ongoing care
• DocScrib’s AI-powered scribe transforms note-taking into a fast, seamless process