John McAfee once said: “I think that it’s when we step out of the road, step outside the box, become our own person, and we walk fearlessly down paths other people wouldn’t look at, that true progress comes. And sometimes true beauty as well.” Real progress can be attained if a person is willing to take the risks and challenge himself to make necessary steps towards self-transformation.

Are you a health professional like a clinical psychologist who works to help people change for the better versions of themselves? If yes, this article will be helpful for you in writing client centered progress notes.  So, we include some progress note templates to guide you in your work. Keep on reading!

FREE 10+ Client Progress Note Samples

1. Client Progress Note Sample

 

Details
File Format
  • PDF

Size: 22 KB

Download

2. Client Therapy Progress Note Sample

Details
File Format
  • PDF

Size: 63 KB

Download

3. Therapy Practice Client Progress Note

Details
File Format
  • PDF

Size: 332 KB

Download

4. Client Initial Progress Note

Details
File Format
  • PDF

Size: 275 KB

Download

5. Individual Client Progress Note

Details
File Format
  • PDF

Size: 866 KB

Download

6. Client Progress Note And Authorization

Details
File Format
  • PDF

Size: 27 KB

Download

7. Blank Client Progress Note

Details
File Format
  • PDF

Size: 91 KB

Download

8. Client Progress Note Checklist

Details
File Format
  • PDF

Size: 111 KB

Download

9. Client Mental Health Progress Note

Details
File Format
  • PDF

Size: 5 MB

Download

10. Printable Client Progress Note

Details
File Format
  • DOC

Size: 20 KB

Download

11. Editable Client Progress Note

Details
File Format
  • DOC

Size: 5 KB

Download

 

What is a Client Progress Note?

A client progress note is a significant document that contains primary aims and objectives, as well as the overall development or progress of your client in his or her physical therapy, rehabilitation for mental health due to drug and alcohol abuse, and other reasons. It provides a clear overview of each therapy session of the client and a comprehensive record of the effects of the therapy to the client.

How to Write a Client Progress Note

Aside from working in treating the problems of your psychotherapy clients who are in distress, you also need to be able to write a comprehensive progress report or progress note of your clients to check and monitor their progress and provide feedback to the clients concerning their progress.  

In this section, we give you some easy-to-follow tips  that indicate how to design a progress note for your clients: 

1. Start the therapy with your client

To identify a treatment that is best suited to a client, you need to start the therapy with your client. Use some questions to dig deeper and unravel what is inside the mind and heart of your client.  The book “Clinical Psychology for Trainees” explained that you should think about how best to manage the therapeutic relationship with your client to foster change. Always review your method and respond to it. 

If you’re a new therapist, don’t worry because you will eventually understand that using two approaches are not mutually exceptional but complement one another. So, do your best effort by becoming warm and friendly to your client. Make eye contact and allow time for small talk like a brief introduction. Then, ask your client about the problem.

2. Assess the needs of your client

After the brief introduction and small discussion with your client, you can now make some assessment of your client’s needs. Research about the diagnosis you made based on his or her condition. Write down the methods and prescriptions that are essential for your client’s therapy. Include all of this information to the client’s progress note as this will be the starting point of his or her progress of the treatment or therapy. 

3. Describe the effects of the therapy to the client

Then, after several weeks of the therapy, clearly describe in detail the effects of the therapy to the client. Take note of the new symptoms that he or she is currently experiencing due to the intake of some medications. If you notice that he or she needs to change his or her medications due to side effects, include this information on the progress note as well.  After that, observe your client for another week or even months, depending on his or her medical condition. Record every little bit of your client’s progress in your note. 

4. Use some tests and visual diagrams

You may use some psychological evaluation tests or assessments to measure the progress of your client. This series of tests is an integral tool to collect information about how your clients think, feel, behave, and react. The findings are utilized to write a psychological report or a progress note of your client’s abilities and behavior, as well as to be the foundation in creating recommendations for his or her treatment.

Additionally, you may incorporate some visual diagrams like charts, bar graphs, and tables to demonstrate the progress of your client as he or she undergoes the therapy. 

FAQs

How to write a progress note for a client?

Remember to use a blue or black pen. When writing a progress note for a client, you need to constantly check the real condition of your client and describe how he or she responds to the therapy. Note the date of your entry and include your signature at the end of the progress note.

What to write in a progress note?

A progress note should include the objectives, goals, relevance, methods, solutions, failures and accomplishments, side effects of the treatments, etc. 

How to write a counseling note?

Select a theme or primary concept for the counseling session with your client. Set up a regular schedule. Look for simple and effective templates that you can use in your counseling sessions. Avoid writing down short and quick notes. Write the events in detail. 

How do you create a daily progress report?

Define the main purpose and the nature of the daily progress report. Classify the organization or business firm’s selected type of reporting. Include some visual representations such as charts, graphs, tables, and diagrams. Keep in mind that your report should remain on topic or concept.

Therefore, writing a progress note for your client is a valuable step in staying productive and organized in your work as a clinical psychologist or psychiatrist. Plus, keeping a complete record of your clients’ progress notes can be helpful in the future. It is clinically useful because you don’t have to wait until post-treatment to identify which clients are going to fare badly because you can predict the end-state of your client if you see the amount of progress made after three sessions into therapy. Thus, monitoring the progress allows you to use  practice-based evidence to guide and inform clinical decisions about the treatment progress. Here are some of our downloadable and printable progress note samples available in different kinds of formats. 

Related Posts