In measuring and demonstrating the patient’s overall improvement while undergoing therapy, you need to be able to write clear and comprehensive therapy progress notes.  These notes will be useful for the health professional, physical therapist, or psychologist to efficiently create the progress of the patient’s treatment sessions. By practicing this method, it will save many hours of time-consuming paperwork and increase your work productivity levels. This article will be beneficial for you in writing the therapy progress note of your patients.  So, we include some therapy progress note templates to guide you in your medical work. Scroll down until the end!

FREE 10+ Sample Therapy Progress Note

1. Psychotherapy Progress Note Sample

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2. Printable Therapy Progress Note

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3. Functional Family Therapy Progress Note

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4. Therapy Progress Note Format

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5. Therapy Progress and Process Note

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6. Standard Therapy Progress Note

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7. Group Therapy Progress Note

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8. Parenteral Nutritional Therapy Progress Note

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9. Editable Therapy Progress Note

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10. Formal Psychotherapy Progress Note

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11. Professional Therapy Progress Note

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What is a Therapy Progress Note?

A therapy progress note is a written record that demonstrates a clear and brief summary of each therapy session of the patient which may include a family, couple, or group that undergoes a physical therapy or mental health treatment session. It can also be referred as a SOAP (Subjective, Objective, Assessment and Plan) note and a DAP (Data, Assessment and Plan) note, 

Moreover, it is a significant document that provides target goals and solid objectives, as well as the whole progress of a patient’s physical therapy, mental health or psychological therapy, rehabilitation for mental health due to drug and alcohol abuse, accidents, trauma, or any other potential causes. 

How to Write a Therapy Progress Note

Helping patients in their therapies is a wonderful way to assist them in their growth and healing process. Be inspired from these words by Corner Canyon Counseling: “Always remember that for each patient you see you may be the only person in their life capable of both hearing and holding their pain.” In this section, we give you some easy-to-follow tips  that indicate how to design a comprehensive therapy progress note for your patients: 

1. Sustain a good therapeutic relationship with your patient

You should think about sustaining a good therapeutic relationship with your patient to promote change and additional progress. Find out and discover what is inside the mind and heart of your patient by using emotional intelligence questions. 

Keep on doing your best effort while displaying warmth and friendliness to your patient. Allow time for small talk. Then, ask your patient about his or her problem.

2. Determine your patient’s needs 

After briefly discussing with your client, you can now determine the physical, emotional, social, and psychological needs of your patient. Carefully review the medical history and research about the diagnosis you made based on 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 patient’s therapy progress note as this will be the starting stage of his or her progress of the therapy

3. Interpret the benefits and effects of the therapy 

Then, after several weeks of the therapy, clearly interpret in detail the benefits and effects of the therapy. Write down the new symptoms that he or she is currently feeling or his or her present condition due to the intake of some medications or other treatments.  

Examine your client for another week or even months, depending on his or her medical condition. Record every little detail of your patient’s progress in your note and you may ask the patient’s parents, guardians or colleagues about his or her condition at home, at school or at work, etc.

4. Use some psychological evaluation tests 

Psychological evaluation tests or assessments are relevant tests that you need to perform so that you are able to effectively measure the progress of your patient’s therapy. This series of tests is a crucial tool in gathering information about how your patients think, feel, behave, and react. The findings are utilized as references to document a psychological report or a physical therapy progress note of your patient’s abilities and behaviors, as well as to be the principal element in formulating recommendations for the treatment suitable for the patient.

FAQs

What to write in a progress note for therapy?

A progress note for therapy should include the patient’s medical history, allergies, prescriptions, symptoms, past and current treatments, latest condition and accomplishments, side effects of the treatments, clinical diagnoses, etc.

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Why do therapists record notes?

The recorded notes are beneficial to the therapists because they can get back or review the essential details and noteworthy aspects of the therapy process, as they remember the recent accomplishments that were made by the patient and monitor the progress of the therapy. 

How to take therapy notes?

When you are taking therapy notes, you must select a basic theme for the session. Then, design a regular schedule. You also need to create a simple template. Avoid writing down quick notes because you need to record every little detail of the patient’s progress while undergoing therapy.

How long should therapy notes be?

If you are writing therapy notes, you need to record notes in 5-10 minutes for a 45-minute therapy session. Also, you need to make a careful review of your notes and see if you need to remove some insignificant points.

Ili Rivera Walter said: “Success as a therapist is not found in doing something for the client, but rather in being something for the client.” For that reason, writing a therapy progress note for your patient is an imperative method in productivity management  and preserving order in your job as a psychologist, physical therapist or mental health professional. Thus, progress notes clearly present improvement in the patient’s physical abilities or cognitive functions, proving that the patient has exhibited progress from his or her therapy or treatment. Here are some of our downloadable and printable therapy progress note samples available in different kinds of formats. 

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