Documenting therapy sessions in the Golden Thread: Progress note template

The Golden Thread shows a cohesive narrative of a client’s experience based on therapist documentation. Progress notes are the third piece of clinical documentation in the Golden Thread, after the intake assessment and the treatment plan. They summarize what occurred in a specific therapy session, including clinical interventions. Progress notes are tied to SMART goals and objectives outlined in the treatment plan. 

When should I use progress notes?

With the exception of an initial assessment (intake) document with a new client or when reopening a former client who was discharged, each therapy session is documented using a progress note.

What information is in progress notes?

A progress note includes:

• Details about the session (start/end times, CPT code)
• Current diagnosis
• Details about clinical interventions used in the session
• Client progress in treatment tied to treatment plan goals 

Progress notes use the SOAP format, and a risk assessment and mental status notation further strengthen the documentation.

If you have a client contact between sessions that is not a billable service or a therapy session, you can document that using the phone/email consultation template.

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How can I get the progress note template?‍

As a resource for SonderMind providers, we’ve created a progress note template that you can access here. 

To help you fill out progress notes, we’ve also developed examples featuring fictional clients. The information in each sample is for illustrative purposes only and does not contain real client information.

• This sample represents the fourth session of therapy, followed by another progress note after four months of therapy for a F33.1 Major Depressive Disorder, recurrent episode, moderate diagnosis - adult‍
• This sample represents the fourth and fifth sessions of therapy for a F43.10 Post Traumatic Stress Disorder diagnosis- adult‍
• This sample represents progress notes for a F41.1 Generalized Anxiety Disorder - teen

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You might also want to read

The Golden Thread: Using Medical Record Documentation Templates to Prove Medical Necessity

Initial assessment in the Golden Thread: Intake template

Road map for care in the Golden Thread: Treatment plan template

Documenting end of care in the Golden Thread: Discharge summary template