How to Write Psychotherapy Progress Notes (continued...)

Patricia C., Ph.D.
Clinical Psychologist
notedesigner.com

Afterword and resources

A summary of what to include and avoid in your Psychotherapy Progress Notes

Include:

Avoid:

Client’s identifying informationPersonal opinions and feelings
Emergency contact personDerogatory comments
Fees for serviceCountertransference feelings
Dates of serviceOpinions outside of your expertise
Referral sourceConjecture stated as fact
Informed consent for treatmentNon-clinically relevant details
Informed consent for any disclosuresUnsubstantiated judgments
Presenting difficulties Names of individuals (unless relevant to crisis management)
Medications used
Clinical impressions (diagnoses if mandated)
Goals of the treatment
All recommendations and referrals made (including the reasons for them)
Type of treatment, techniques, and interventions implemented
Progress and gains made or lack thereof
Treatment plan and ongoing treatment plans
All risk behaviors and issues of safety (danger to self and/or others)
All clinical measures taken in the event of crises (e.g., risk to self and/or others)
Assessment of safety concerns and how you handled them (all interventions made)
Observations regarding child abuse, abuse of a dependent, or elder abuse (and any actions you took or did not take and why)
Consultations with other professionals
Duration of services rendered
Treatment compliance
Nature of the Termination and its impact and management

Resources

Below are links to some samples and templates for the different kinds of notes, as well as selections from the APA guidelines on note-keeping. Good luck with your note taking!

Patricia C., Ph.D.

Sample Intake Note
Sample Progress Note
Sample Termination Summary
APA guidelines

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.

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