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Therapy Progress Notes: The Clinician’s Complete Guide with Examples

Updated on: July 22, 2025

Introduction: Why Progress Notes Matter in Therapy

Progress notes form the cornerstone of clinical documentation in mental health. More than just a paper trail, they serve as vital records of therapeutic sessions, legal protection, tools for insurance reimbursement, and guides for future clinical decisions. When done effectively, therapy progress notes capture the essence of client care and empower clinicians to track change over time.

Yet many therapists still struggle with what to include, what not to include, and how to write them efficiently. This guide will walk you through how to write high-quality therapy progress notes, popular formats (like SOAP and DAP), sample templates, and documentation best practices.


What Are Therapy Progress Notes?

Therapy progress notes are concise summaries written by clinicians after each session with a client. They provide a snapshot of:

  • What occurred during the session
  • The client’s status and progress
  • Clinical interventions and observations
  • Future treatment planning

Unlike psychotherapy notes (which are private and kept separate under HIPAA), progress notes are considered part of the medical record and can be accessed by insurers and clients upon request.


Common Formats: SOAP vs DAP vs BIRP

Clinicians typically follow structured note formats to ensure consistency and clarity. The three most widely used frameworks are:

SOAP Notes

Section Purpose
Subjective Client’s reported thoughts, feelings, symptoms
Objective Observable behaviors, test results, clinician observations
Assessment Clinical interpretation or diagnosis updates
Plan Next steps, treatment goals, follow-up

Example:
S: “I’ve been feeling less anxious since our last session.”
O: Client was relaxed and smiling throughout the session.
A: Anxiety symptoms are decreasing; client responds well to CBT.
P: Continue CBT, assign journaling exercise.


DAP Notes

Section Purpose
Data Objective and subjective info combined
Assessment Clinician’s interpretation and insight
Plan Follow-up strategy and homework

Example:
D: Client expressed concerns about work-related stress. Appeared tense.
A: Client is overwhelmed due to job insecurity. High stress response.
P: Teach deep breathing, assign daily self-care log.


BIRP Notes

Section Purpose
Behavior Client’s actions, emotions, or verbalizations
Intervention Therapist techniques used in session
Response Client’s reaction to intervention
Plan Treatment continuation plan

Example:
B: Client discussed recurring nightmares and guilt.
I: Introduced grounding techniques and cognitive reframing.
R: Client appeared calmer, expressed optimism.
P: Practice grounding daily; revisit trauma narrative next session.


What to Include in Every Progress Note

While formats vary, a strong therapy progress note generally includes:

  • Session date/time and duration
  • Client name/ID
  • Presenting issue or symptoms
  • Clinical observations (mood, affect, appearance)
  • Techniques/interventions used
  • Progress toward goals
  • Any client statements relevant to care
  • Plans or changes to treatment goals
  • Clinician’s signature and credentials

🔒 Note: Always avoid including private reflections, irrelevant personal info, or speculative comments not grounded in clinical observation.


Sample Therapy Progress Note (SOAP)

Client: John Doe
Date: July 21, 2025
Duration: 50 minutes
Format: SOAP

S: “I’ve been sleeping better, but I still get overwhelmed at work.”
O: Client appeared well-groomed, engaged, and attentive. No signs of acute distress.
A: Signs of reduced insomnia, yet moderate anxiety persists. Client remains receptive to CBT.
P: Assign workplace journaling; explore time-management skills in next session.


How to Write Notes Faster Without Losing Quality

Documenting after each session is critical—but it shouldn’t become a burden. Here are expert tips:

  • Use an AI medical scribe like DocScrib for real-time transcription and note generation
  • Create templates with dropdowns or checkboxes in your EHR
  • Dictate notes using voice-to-text tools
  • Write bullet points, then expand key sections
  • Schedule “note power hours” post-sessions to batch-write effectively

Chart: Comparing Therapy Note Formats

Feature SOAP DAP BIRP
Most Structured
Ideal for Insurance
Encourages Interpretation
Widely Recognized Medium Medium

Legal & Ethical Considerations

Therapists are legally required to maintain documentation that is:

  • Accurate
  • Timely
  • Confidential
  • Clinically relevant

Key Guidelines:

✅ Document within 24–48 hours
✅ Store notes in secure, HIPAA-compliant systems
✅ Avoid bias or language that could be misinterpreted in legal settings
✅ Use professional tone even when quoting clients


Real-Life Case Example

Client: A 29-year-old female struggling with social anxiety
Session Summary:
Client described persistent fear during group meetings at work. Therapist used role-playing exercises to rehearse positive affirmations and body language. Client initially hesitated but eventually participated with increased confidence.

Note Extract (DAP):
D: Client described fear of judgment. Avoids eye contact.
A: Social anxiety impacting job performance.
P: Encourage exposure tasks; track feelings after meetings.


How Many Progress Notes Should Be Written?

You should write one progress note per session—whether it’s individual, family, group, or telehealth. For extended sessions (90+ minutes), a detailed note may be required. Missed sessions don’t require progress notes but can be documented as no-shows with billing status.


Common Documentation Mistakes to Avoid

❌ Writing overly vague notes like “Client was fine”
❌ Using unapproved abbreviations
❌ Mixing personal opinions with clinical observations
❌ Copy-pasting identical notes across sessions
❌ Ignoring measurable progress markers


Digital Tools That Can Help

Use HIPAA-compliant tools such as:

  • DocScrib – AI-powered therapy scribe
  • SimplePractice – EHR with built-in note templates
  • TheraNest – Client progress trackers
  • Google Voice Typing – Fast dictation
  • Zapier + Notion – For creating automated note logs

Infographic: What Makes a Great Therapy Progress Note?

A great note is:
✅ Accurate
✅ Specific
✅ Professional
✅ Legible
✅ Linked to treatment goals
✅ Completed promptly

(Insert infographic here)


How Progress Notes Impact Clinical Outcomes

When done consistently, progress notes lead to:

  • Better treatment tracking
  • Stronger therapeutic alliances
  • Fewer compliance issues
  • Faster insurance approvals
  • Improved clinical decision-making

According to research published in JAMA Psychiatry, therapists who consistently document patient outcomes via progress notes report higher recovery rates in outpatient mental health care.


When to Use Addendums

If you realize you missed something after submitting a note:

  • Don’t delete the original note
  • Add an addendum with the date, time, and correction reason
  • Sign again

FAQs About Therapy Progress Notes

Q: Are progress notes the same as psychotherapy notes?
A: No. Progress notes are part of the medical record and accessible to clients/insurers. Psychotherapy notes are private.

Q: Can I handwrite therapy notes?
A: Yes, but digital is preferred for accessibility, backup, and billing.

Q: Can AI write notes for me?
A: Tools like DocScrib can generate high-quality draft notes using voice input or session data—always review before signing.


Conclusion: Better Notes Lead to Better Care

Writing effective therapy progress notes isn’t just an administrative task—it’s an act of clinical integrity. It ensures continuity, safety, and measurable progress for your clients.

With structured formats like SOAP or DAP, tools like DocScrib, and consistent documentation habits, clinicians can make their notes work for them—not against them.


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