How to Write Psychotherapy Progress Notes (continued...)
Patricia C., Ph.D.
1) Opening a File: The Intake Report
The first type of documentation that is needed in any psychotherapy file is the Intake Report. This is a general overview of the information collected during the assessment period of the prospective psychotherapy treatment. The Intake Report documents certain essential pieces of information as is required by most institutions and professional orders or colleges. Below is an example of the types of identifying information that normally begins a clinical file and the Intake Report. Following that you will find an outline of the main sections of the report with a brief description of what each section should contain. You can also Click Here to read a sample Intake Report as loosely based on a file from my practice.
This section often begins with some introductory comments and/or behavioral observations regarding the client’s (or "patient's", as you prefer) appearance, initial presentation, and manner of interacting with the therapist and the therapeutic environment. Be careful to refrain from comments that could come across as personal opinion or as evaluative in tone (e.g., “the client didn’t bother to remove his boots upon entering the office, even after I asked him” versus “the client kept his boots on during the interview, despite being requested to remove them”). The idea here is to keep the tone observational and dispassionate. Always keep in mind that your client may read his or her file and it is important that there is nothing in the file that could be harmful or hurtful for the client to read.
The main content then moves to a description of what brings the client to be seeking help at this time. Typically, this will involve restating what the client reports to you as his or her reason for wanting help. It is important that this portrays an account of the client’s perspective.
It is sometimes helpful to use actual quotes from what the client stated and to use phrases such as “The client reported…”, “According to the client…” or “The client stated that….” The point here to remember is not to include your interpretation of what the client is saying but mostly your observation of what the client is telling you. This is especially important when the client is also referring to the actions and characteristics of other people (e.g., “The client’s mother has numerous extramarital affairs and cheats on her taxes” versus “The client stated that she believes her mother has numerous extramarital affairs and cheats on her taxes”). Bear in mind that unless you’ve seen the family members/colleagues/friends/etc. yourself, you are only able to recount the perspective of the client.
Reminder: As in all sections of the report and the client’s file, be careful not to include any proper names of people the client mentions (the use of an initial is a better option).
History of the Presenting Difficulties:
In this section, you briefly recount the history of the client’s presenting problems. For instance, this might include events leading up to the beginning of the difficulties, some background regarding the environmental or social conditions faced by the client that may be relevant to the presenting difficulties, details regarding the first appearance of the difficulties, and any past attempts at seeking help and their outcome(s).
As described in the section above, when reporting on what the client has told you, try to maintain an observational or journalistic style. If you want to include any statements regarding your own understanding or broader interpretation of what the client is reporting, it is important to preface these with phrases such as “It appears as though…”, “There was some suggestion that...”, “I had the impression that the client was struggling to describe…”, “Though the client reported having fully recovered after her first depressive crisis, her difficulty maintaining her relationships and hobbies suggests that the depression may have persisted”. While on the topic of how to include our own clinical impressions and interpretations, I suggest that you try as best you can to support all of your own impressions by including the information you are using to get there. By doing this, you are strengthening the validity of your report and will help others (including the client) better understand your conclusions if there arises the need to share the report.
Significant Life History and Background Information:
Here you summarize the background information and life history of the client as based on your Intake interview(s). For instance, you here include details regarding the client’s family of origin, siblings, significant interpersonal and romantic relationships and children. As well, you might include here a summary of how the client described his or her family members, childhood experiences, and past traumas or difficult experiences. You might also here include a description of the client’s educational and work history as well as a description of any hobbies, interests or other information important to understanding the client as derived from your interview.
It is usually helpful to organize this section into paragraphs that fit the different aspects of the client’s history. You might even use subheadings to lend further structure (e.g., Family Background, Educational and Work History, Childhood and Adolescence, Developmental History, Marital and Family Relations, Sexuality, Hobbies and Interests, etc.).
As described above, be sure to be mindful to keep the tone journalistic, nonjudgmental and non-evaluative. Again, make good use of phrases such as “The client reported that..”, “According to the client…”, “ The client further explained…”. And again, if you feel it is important to include your own impressions, use a style that signals that this is your conjecture “In speaking so briefly and positively about his family, I had the impression that he may have been uncomfortable disclosing more personal information at this time” etc.
Significant Medical History:
In this section, you briefly describe the significant medical/physical issues reported by the client during the intake assessment (as a reminder: it is generally recommended a mental health practitioner take a medical history as part of the intake assessment). Unless you are also a medical practitioner (and so may have reason to do otherwise), here you are basically recording what the client has reported. For example, we will record things such as reported past illnesses, surgeries, hospitalizations, chronic health conditions, accidents that required medical attention as well as the client’s overall tendency towards ill physical health and somatic symptoms (e.g., frequent headaches, nausea, constipation etc.). Medications that the client is taking are also noted in this section (whether you need include the dosages and exact names of the client’s medications will depend on the nature of the case, the requirements of the institution or jurisdiction where you are working, and your own professional credentials).
Clinical Observations and Impressions:
This section is a place for the clinician to record (in greater detail than what was stated under “presenting difficulties”) his or her observations and impressions of how the client behaves, comes across, interacts, and responds to the clinical situation. This might also include the overall results of any testing that was conducted during the intake processes (e.g., Beck Depression Rating Scale, Symptom Checklist, Mini-Mental exam etc.). As well, you would include here the nature and results of your risk assessment (if deemed necessary). The information provided in this section will serve as the basis for your Diagnostic impressions and Preliminary Clinical Formulation that will follow. As in other sections of the report, please be careful not to inadvertently use a pejorative tone or state anything that might be hurtful or harmful if the client were to read the report.
As based on your clinical observations and impressions, here you briefly state your diagnostic impressions. If you are a Psychiatrist or Medical Professional or are in a state or province where you have the mandate to use DSM diagnoses this is where you record your preliminary diagnosis/diagnoses and corresponding DSM code(s) (if necessary or required). It is important to substantiate your diagnosis or diagnostic impression with the data you observed (as outlined in other sections of the report). It is often helpful to use phrases such as “The client’s clinical presentation is consistent with a diagnosis of ...” or “The client meets the DSM-V criteria for a diagnosis of …” as a means of conveying your impression. For those clinicians who do not use official diagnostic categories, this section of the report is used to describe the main difficulties that will be the focus of the psychotherapy (e.g., “the client struggles with depressed feelings and anxiety that interfere with her ability to leave the house”, “The client appears to be experiencing a prolonged mourning and grief reaction following the death of her husband 2 years ago” etc.). In this section you may also make note of any diagnoses (past or current) as reported directly by the client; take care to stipulate that this was stated by the client himself or herself (e.g., “It should be noted that the client reported that one of his psychiatrist told him he had borderline personality disorder”).
Preliminary Clinical Formulation:
In this section, the clinician describes his or her formulation or clinical understanding of the client, the clinical picture, and/or the symptoms and behaviors that will be the focus of the treatment. The style of your Preliminary Clinical Formulation will be influenced by your theoretical orientation and/or the orientation that you see may best address the situation with the particular client. Thus, a psychodynamic or analytic clinician may place emphasis on the potential underlying conflicts, fantasies and past experiences that may be part of the clinical picture whereas a cognitive-behavioral therapist may place more emphasis on current life events, the development of a particular cognitive style or schema, and learned patterns of responding and behaving. Regardless of one’s theoretical orientation, this section should present your views in a somewhat tentative manner – one that acknowledges the preliminary nature of the formulation. Thus again, phrases such as “It appears…”, “It seems likely that…”, “Though speculative at this time, it seems that the client…”, “It may be hypothesized that the client…”, are helpful to convey the preliminary nature of this aspect of the report.
Recommendations and Preliminary Treatment Plan:
In this section, the clinician first supplies his or her clinical recommendations. For example, this will include the recommendation that the client be seen in psychotherapy at a certain frequency and for a certain period of time. It may also include the recommendation that the client be referred for such things as psychological testing and/or a psychiatric consultation and/or consultations with other professionals (e.g., a couple or family therapist) or organizations (e.g., social services, employment centers, shelters etc.). In addition to your recommendation(s), you should also offer some explanation as to why such a recommendation is being made and/or for what particular problem or aspect of the problem (e.g., “A short-term psychodynamic therapy at a frequency of twice per week was recommended so as to help the client better understand and resolve the prolonged mourning over the loss of her husband.”, “It is recommended that the client commence a cognitive-behavioral treatment at a frequency of once per week to help him address how his cognitive style impacts his panic attacks and phobic avoidance of women”). Here we might also briefly mention the factors that support our recommendation (e.g., “Though the client stated that she found her previous group therapy helpful, she indicated that she is now interested in better understanding how her past experiences with loss are affecting her coping with her current relationship anxieties; thus a psychodynamic approach appears indicated.”) In this section you might also sometimes include what is not recommended and why (e.g., “It appears that an individual psychotherapy may, at present, be too emotionally overwhelming for the client given her reported recent erotomanic episode with her previous individual therapist, thus it is recommended that the client receive supportive group therapy”.)
Once you have stated your recommendations, it is time to describe the preliminary Treatment Plan. If you have made recommendations for consults with other professionals or organizations, you would here mention how you have facilitated or are going to facilitate this. With respect to any recommendation for treatment that you will be doing with the client, it is here where you mention the goals for treatment and the methods and/or techniques to be used (e.g., “exploration and interpretation of underlying conflicts and fantasies”, “bibliotherapy”, “relaxation techniques”, “mindfulness exercises”, “homework assignments”, “understanding and exploration of the therapeutic relationship” etc.)
Description of Treatment Contract and Informed Consent / Additional Comments:
The last section of the Intake Report provides documentation regarding the manner in which you explained the treatment recommendations, the nature of the treatment (including what to expect from the treatment), as well as what is expected of the client as part of the treatment contract (e.g., nature of attendance, cancelation policy, fees, etc). Depending on your particular professional college, order, or licensing body you may be required to have the client read and sign a consent form for treatment; if so, it is here that you explain that you took this measure (as well as keeping a copy of the consent form in the file itself). If a consent form is not used, it is particularly important that you here document how and that you obtained verbal informed consent from your client.
As with all things documented in your client’s file, be sure to include your official signature line and to promptly sign the document once it is printed.
_______________________________ Patricia C., Ph. D. Psychologist
Note: Recommendations and examples presented are intended to provide a general overview of how to write psychotherapy progress notes and do not constitute nor can they substitute for legal counsel or official guidelines mandated by any particular professional order or other regulatory body; please be sure to consult and familiarize yourself with the guidelines and rules regarding record keeping in your particular mental health field and/or as stipulated by your profession.