How to Write Psychotherapy Progress Notes (continued...)
Patricia C., Ph.D.
2) Maintaining a File: The Session Note or Progress Note
Once psychotherapy has begun, a mental health practitioner must keep notes on what transpires during each session. There are specific topics and types of information that such a Progress Note should contain as well as many things it should not. In this section, I will first indicate the types of identifying information that begin each Progress Note and then briefly outline the structure of a basic Progress Note that can be used to guide and organize its content. Along the way I will offer some general direction regarding what to include and what not to include in such a note (as derived from the Guidelines of the American Psychological Association and the Canadian Psychological Association). You can Click Here to read a sample Progress Note.
Global Assessment of Functioning:
It is helpful to begin a note with a short description of the client’s overall level of functioning. Here you may include a few statements regarding the level of severity of the client’s struggles (I tend to use the Global Assessment of Functioning Scale from the DSM as a general guide). For example, “The client's estimated global assessment of functioning suggests a moderate degree of emotional distress and difficulty dealing with relationships, work and/or school life.” or “The client's estimated global assessment of functioning suggests that the client is in some danger of harm to self or others and is having serious difficulty maintaining self-care and basic life functioning”.
Affective and emotional state:
Next, I suggest providing a brief description of the main emotional state(s) evidenced by the client. You might also note whether and in what way his or her emotional state changed over the course of the session. Keep in mind that both negative and positive emotions should be included where appropriate (we tend to focus more on the presence of negative emotions as clinicians).
You might also make brief mention of the client’s overall mental or cognitive state: For example, whether he or she was able to adopt a reflective stance, whether the client comes across as dissociated from his or her experience, any evidence of confusion, poor judgment, suicidal ideation, hypomanic features, obsessional preoccupation, improved judgment, or perhaps a strong capacity for reflection and insight.
Main themes of the session:
Next I suggest listing the main topics and issues that emerged or were discussed and explored by the client. In the interest of keeping a concise note that does not also expose too much of the client’s personal information, I suggest using general categories to describe what was explored. For instance, instead of saying that “the client described how on Saturday night she threw a dish on the floor while she and her husband were fighting and that she thought she never should have married him and called him a jerk….etc.” you might simply state “The client explored a recent relational conflict with her husband and her difficulties containing her rage and aggressive feelings”. By restricting the content to a general overview you are less likely to reveal something in the client’s file that may be potentially detrimental to the client’s well-being if read by a third party (such as when a file is requested by an insurance company or if required by the courts) or by the client himself or herself in the future.
There are times when it is important to document in detail what has transpired during a session. This is the case when a client discloses content related to a wish to cause harm to self or others, or in the case of possible abuse of a child or other vulnerable person. In such situations, you should carefully document what the client has reported in detail as well as all interventions you took to assess and address the potential crisis. Keep in mind that in the event of any question regarding your management of a case, your documentation is what can protect you in the event of litigation. You must be able to demonstrate that you took all appropriate and reasonable clinical measures to protect the client and/or people at risk in a manner consistent with the current standards in the profession.
Main therapeutic interventions:
In order to be accountable for the work we do with clients, it is very important that we document the interventions we make during a session. Thus, in addition to describing the themes and issues raised during the session, we must also make some mention of what we ourselves did during the session to address the client’s difficulties. For instance, in the case of a psychodynamic treatment the clinician should mention the types of interpretations made, in cognitive-behavioral therapy, the clinician should mention any techniques suggested and/or homework assignments reviewed or assigned, while in a supportive treatment the clinician should mention any guidance and problem solving help provided to the client. Of course, sometimes our main intervention may simply include active listening and providing some reflective statements regarding the client’s experience. Regardless of how active or inactive you have been during a session, it is important to provide some documentation regarding how you intervened and/or whether you chose not to intervene as may be required by the clinical situation.
Developments, treatment plan, outlook and ongoing issues:
The last section of your note should make some mention of any significant developments or progress that the client has made as observed in the session or reported by the client (e.g., “The client continues to make steady gains in self-esteem and confidence”). As well, you should here include a brief statement regarding the treatment plan (in particular any changes to the original treatment plan as set out in the Intake Report should be noted). In the case of ongoing psychotherapeutic work where there is no change to the treatment plan we might simply state something like, “The ongoing treatment plan includes continued support and maintenance of the psychotherapeutic process”. Finally, it is important to make mention of any outstanding clinical issues (e.g “The client's help-rejecting behaviors remain a significant therapeutic concern”.
At the tail end of the note, you may sometimes wish to include further details that you think should be noted from a session: For instance, issues regarding late payment, changes in the therapeutic contract, requests for information, instructions regarding an holiday schedule, or significant up-coming events in the client’s life that may have an impact on his or her well-being and/or the therapy process.
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.