Progress Notes Template
This mental health progress note template is designed for psychiatrists, psychologists, and other mental health clinicians to comprehensively document patient visits. A complete behavioral health progress note template, it covers patient history, current status, mood, mental state, social functioning, physical health, and a detailed treatment plan.
- Efficiently capture all relevant details required to complete a detailed, high-quality progress note.
- The template is adaptable to the needs of all mental health clinicians (in both inpatient and outpatient settings).
- AI automatically collates information from the appointment into a completed progress note for the clinician to review.
What is a Progress Note Template?
Progress notes are a type of clinical documentation healthcare providers use to record updates and changes in a patient’s condition. Clinicians of all backgrounds produce progress notes during outpatient follow-up appointments or patient reviews in hospital settings.
Many clinicians use a progress note template to streamline the process of writing follow-up notes. These templates may follow an existing format (like SOAP, DAP, or BIRP), but it’s just as common for providers to use a custom progress note template.
In this article, we’ll explore common clinical scenarios where progress notes are used. Then, tips for finding the right progress notes template are discussed, followed by an explanation of how AI can automate progress notes.
Clinical Scenarios Involving Progress Note Templates
Progress notes are a fundamental type of clinical documentation in all practice settings. In addition to capturing key events throughout the course of a patient's treatment, progress notes also serve as a communication tool between providers.
To give you an idea of the use cases for a progress notes template, we’ve detailed some common clinical scenarios involving the documentation of follow-up appointments below.
Primary Care Follow-Ups
Primary care doctors often see patients for consecutive appointments regarding new or chronic conditions. The initial visit is usually a long consultation involving an assessment and detailed note. Then, subsequent visits are captured on a medical progress note template describing events since the last appointment and the patient’s present condition.
For example, a primary care doctor may notice new onset hypertension during an annual physical with a patient. A preliminary treatment plan to trial lifestyle changes could be implemented during this appointment, with monthly reviews to monitor response.
At each monthly review, the doctor would complete a progress note detailing the patient’s response to interventions, changes to the treatment plan, and any new issues that arise.
Inpatient Medical Treatment
Progress notes are written by all members of a multidisciplinary inpatient team. These notes are often written daily, using a specific nursing progress notes template or internal medicine progress note template. The progress note keeps all members of the treatment team up to date with results, the clinical rationale behind treatment plans and the patient’s progress in real time.
Alternatively, some inpatient teams utilize a generic progress note template where clinicians of all backgrounds document a patient’s current status and treatment plan.
If we use a short stay medical ward as an example, most patients would have a progress note written by their medical team once per day during ward rounds. This typically details current medical status, any changes to treatment, input required from other specialties, follow-up tasks, and discharge planning.
All other members of the MDT would then add their own progress notes, detailing input provided, any follow-up required, and recommendations in context of the patient’s overall management plan.
Chronic Disease Management
All clinicians providing ongoing treatment and management of chronic disease write progress notes. A good chronic disease or case management progress note template includes sections to describe the patient’s history, current presentation, changes to treatment, and future plans or next steps.
Progress notes for chronic disease management are often tailored to the condition being treated.
For example, an endocrinologist seeing a patient for follow up diabetes management would specifically assess and comment on the patient’s glycemic control, medication adherence, diet, and other diabetes-specific risk factors (like foot care and retinopathy screening).
Often, prompts to address these areas are included directly in a customized progress note template.
Mental Health Care
Most psychiatric conditions require ongoing care, consisting of medication management, counseling, and psychoeducation. A high-quality mental health progress notes template helps providers efficiently capture and record all the complex and nuanced patient details that occur in behavioral health care.
A common clinical scenario involving mental health progress notes might be that after starting a patient on anxiolytic medication and referring them for psychotherapy, a psychiatrist sees a patient for fortnightly follow-up appointments.
During these appointments, progress notes would include a review of the patient’s mental state, response to pharmacological treatment and psychotherapy, and whether any risks or other factors warrant a change in management.
Allied Health Management
Whether in outpatient, inpatient, or community settings, allied health providers regularly write progress notes to document a patient’s treatment and recovery.
Providers often use a discipline-specific template, like a physical therapy progress notes template or social work progress notes template. Such templates ensure that general progress is recorded alongside important clinical assessments and observations.
For example, progress notes from a physical therapist working with a geriatric patient post fractured NOF would likely be focused on pain, mobility, and functional limitations. However, progress notes from a social worker seeing the same patient might predominantly be about the patient’s home environment, family support, and emotional well-being.
Tips for Finding the Right Progress Notes Template
Once you’ve decided to use a progress note template, you’ll need to find one that suits your needs. Here are some tips for finding the right template for your practice setting and personal documentation preferences.
- Select the best format - Choose a template format (eg., SOAP, DAP, BIRP, or custom) that aligns with your clinical specialty and record-keeping requirements.
- Look at examples - Compare different progress note templates used by colleagues or online to narrow down your preferences and requirements.
- Prioritize usability - Completeness and level of detail are important. However, longer and more complex templates can compromise ease of use.
- Consider customization - Even the best progress note template may require some tweaking, so be sure to check customization options.
- Search widely - Databases such as Heidi’s Template Community allow you to evaluate dozens of specialty-appropriate templates, all in one place.
After deciding on a progress notes template, test it out in some sessions. If it doesn’t work as well as expected, don't be afraid to try another one. High-quality progress note templates are proven to improve documentation timeliness and note quality, so putting the time into finding the right template is worth it in the long run.
Dr. Lisa Gibson, Psychologist and Sexologist, found that developing her own values-based progress notes template within Heidi saves her over 2 hours in documentation time per day. “I find now that my admin can be done amongst seeing my clients,” she states. “It’s no longer this additional thing I have to do.”
How to Write a Progress Note with Examples
The specific structure of progress notes vary according to the practice setting and preferences of the clinician. However, most follow-up notes adhere to a similar broad structure addressing several key themes.
The main sections of a progress note are described under headings below. Completed notes can be presented with headings or as plain text in paragraph format.
Introduction
Begin with basic identifying information, including patient name, session date, and reason for visit. If desired, the clinician may also include additional personal details about the patient, such as marital status and living situation.
Example: Follow-up visit for Jane Smith in psychiatry outpatient clinic on 02/25/2025. Purpose of visit is ongoing management of major depressive disorder and generalized anxiety disorder.
Patients history and current status
Briefly summarize relevant history and events since last appointment. Usually includes a summary of treatment and response thus far. Notable events since the last appointment can be introduced here.
Example: Patient has been taking sertraline 100mg daily for 6 weeks with partial improvement in depressive symptoms. Reports completing 2 of 6 recommended CBT sessions since last visit. No negative side effects or concerns with medication reported.
Presentation during appointment
Describe the patient’s general appearance and presentation during the appointment. The clinician may comment on physical appearance, demeanor, other people in attendance, and the patient’s engagement with the session.
Example: Patient arrived on time, appropriately dressed, and well groomed. Attended clinic with husband, who sat in the waiting room during the appointment. Describes mood as 6 out of 10, claiming, “I’m feeling a little better compared to last month.” Affect appeared brighter than last visit 4 weeks ago.
Assessment and treatment discussions
List any objective findings, test results, and clinical assessments performed. This section may be broken down into subheadings or separate paragraphs (eg., mental state, physical health, social functioning, substance use).
Example: PHQ-9 score decreased from 16 to 12, indicating moderate depression with improvement. GAD score is 10, down from 14, with patient still reporting feeling anxious “most of the time.” Discussed relationship between work stressors and anxiety. Patient engaged well in problem-solving exercises around establishing better work-life boundaries.
Plan and recommendations
Provide details of treatment decisions, medication changes, referrals, and any specific follow-up actions to be completed by the clinician and patient before the next session. May be written as a paragraph, list, or combination of both.
Example: Plan
- Continue sertraline 100mg daily
- Continue fortnightly CBT sessions with clin psych
- Patient to implement strategies around establishing work-life boundaries (leaving office by 6pm, not bringing work home, setting realistic deadlines with manager)
- Review in clinic in 4 weeks
Progress Note Template Sample PDF
Having a good progress note template definitely saves time on documentation. However, many clinicians still struggle with balancing the need to take comprehensive notes during a session and giving the patient their full attention. It’s also common to not have enough time to complete progress notes between sessions, resulting in a large amount of notes still needing completion at the end of the day.
Automate Progress Note Writing with Heidi
Heidi’s advanced AI medical scribe harnesses the power of ambient AI to automatically generate progress notes. By choosing one of Heidi’s many customizable progress note templates, you can focus entirely on your patients during follow-up sessions, safe knowing that Heidi’s looking after your notes.
Here’s how Heidi works:
- Transcribe - Press Start and Heidi processes every detail from your appointment.
- Customize - Personalize notes with customizable templates and additional context.
- Transform - In addition to progress notes, Heidi generates referral letters, patient summaries, treatment reports, and can even suggest billing codes.
With unparalleled security standards, Heidi is compliant with region-specific healthcare data regulations (eg., HIPAA, PIPEDA, GDPR) across the globe. Over 100,000 clinicians in 50 different countries trust Heidi to streamline clinical documentation in all areas of practice.
Free Progress Note Templates
Medical Progress Note Template
This free progress note template is designed for primary care doctors and physicians to efficiently document patient progress in hospital settings. The template covers investigations, treatment plans, and discharge planning.
Internal Medicine Progress Note Template
Designed by an internal medicine specialist, this follow-up template includes sections for the referral reason, patient history, physical exam findings, and a summary and plan. It’s suitable for inpatient settings and as an outpatient progress note template.
Mental Health Progress Note Template
This follow-up appointment template includes a dedicated section at the beginning that summarizes key findings from the previous session. It’s ideal for psychiatrists and other mental health clinicians to compare current findings with past appointments.
FAQs About Progress Note Templates
What not to include in a progress notes template?
In general, a progress note template shouldn’t include full management plans, treatment reports, or formal assessments. If you need to complete more structured documentation like this at a follow-up assessment, it’s best to use a dedicated template for the assessment or report, with a brief accompanying progress note describing what was undertaken at the session.
What is the most recommended format for progress note templates?
Some clinicians use a SOAP notes template or mental state examination template to record progress notes, but there is no universally recommended “best” format. Each clinician should evaluate which progress note template is most suited to their practice needs and personal preferences.
How can I create my own progress note template?
Heidi allows you to create your own progress note template with our AI-powered template editor. You can: 1) Give Heidi a reference note to turn into a template; 2) Edit an existing progress note template from the community; 3) Create your own progress notes template from scratch. Full instructions are available in our Help Centre article, Creating Templates in Heidi.