The book “Handbook of Clinical Social Work Supervision” stated that most clinical agencies require an initial database, an initial treatment plan, progress notes, and a review treatment plan. Thus, a social worker should develop an understanding that clinical record keeping is a vital process. Are you a medical professional or social worker who  helps people transform themselves? If yes, this article will be helpful for you in writing the progress note of your clients.  So, we include some progress note templates to guide you in your social service work. Keep on reading!

FREE 7+ Sample Progress Notes for Social Workers

1. Progress Notes for Social Workers

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2. Social Worker Blank Progress Note

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3. Editable Social Worker Progress Note

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4. Standard Social Worker Progress Note

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5. Social Worker Progress Note Sample

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6. Printable Social Worker Progress Note

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7. Social Worker Progress Note

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8. Professional Social Worker Progress Note

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What is a Progress Note?

A progress note is an essential document that comprises specific targets and objectives, as well as the whole development or entire progression of your client’s physical therapy, rehabilitation for mental health due to drug and alcohol abuse, or any other reasons. 

Also known as a SOAP (Subjective, Objective, Assessment and Plan) note and a DAP (Data, Assessment and Plan) note, it provides a clear overview of each therapy session of the client or patient and a well-detailed record of the effects of the therapy to the client.

How to Write a Progress Note

Apart from facilitating some treatments for your psychotherapy clients, you also need to be able to write a structured and well-detailed progress report,  DAP note or SOAP note of your clients to check and monitor their progress and show feedback to the clients about their progress in their therapy.  

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

1. Establish a good therapeutic relationship with your client

Use some helpful questions to dig deeper and reveal what is inside the mind and heart of your client.  According to the book “Clinical Psychology for Trainees”, 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. 

Do your best effort by showing warmth and friendliness 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 your client’s needs 

After initially discussing with your client, you can now create some assessment of your client’s needs. Research about the diagnosis you made according to his or her condition. 

Take note of the methods and prescriptions that are crucial for your client’s therapy. Include all of this information to the client’s progress note as this will be the beginning phase of his or her progress of the treatment or therapy. 

3. Explain the effects of the therapy to

Then, after several weeks of the therapy, clearly explain in detail the effects of the therapy in your SOAP or DAP note. Take note of the new symptoms that he or she is currently feeling due to the intake of some medications. If you see that he or she needs to change his or her medications due to some side effects, include this information on the progress note as well.  

Make some careful observations of 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 evaluation tests and visual diagrams

Use some psychological evaluation tests or assessments to measure the progress of your client. This series of tests is a helpful tool in gathering 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 basis in developing recommendations for his or her treatment.

Plus, 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

What to write in a progress note?

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

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How to write a progress note for a client?

First, 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. 

How do you create a daily progress report?

Determine the main purpose and the nature of the daily progress report. Include some visual representations such as charts, graphs, tables, and diagrams. Keep in mind that your report should remain on topic or concept.

How to write a counseling note?

Choose 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. 

In conclusion, writing a progress note for your client is a crucial method in keeping productivity and maintaining order in your job as a social worker. Some view record keeping as a time-wasting chore that exists only for administrators. But you must consider that progress notes show improvement in the client’s functioning, as they prove that the client has made progress in his or her treatment. So, closely monitoring the progress of your client greatly assists you to utilize  practice-based evidence to guide and inform clinical decisions about the treatment progress of your client. Here are some of our downloadable and printable progress note samples available in different kinds of formats. 

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