Making therapy progress notes is vital to the progress of clients who may be suffering from illnesses since it contains details to where the client stands his treatment. While other clinical specialists consider progress notes as mere compliance to their profession and are sometimes not done with the most important details deemed important to the treatment’s progress.
Careful documenting the progress of a patient’s or a client’s journey throughout their treatment plan can be tedious and lengthy but is certainly needed as a basis if there are needed changes to the treatment process or if there are concerns along the way. With its great importance, how do clinical practitioners go about making their progress notes so that they can achieve their intended purpose? If you are also looking to make your own therapy progress notes, check out our free and downloadable templates to get you started. Read on.
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Elements of a Therapy Progress Note
- Process Change
The therapist or the documenter should be able to record the changes of the client in response to different activities, counseling, and medications throughout the whole treatment plan. Progress notes should be specific in pointing out which part of the process causes the drastic change to the client in counseling activities like specific interventions, assignment, topic, discussion, and film in individual, group, or psycho-ed among others. All of these are conducted coinciding with taking in medications as the most important activity. In order to religiously follow and closely monitor the client’s changes, counselors or therapists may need to take turns in different shifts at different time slots.
- Counselor interventions
This refers to the different kinds of interventions that therapists or counselors do to push their clients to make significant progress in their treatment. These are done in ways that are creative and systematic ways that do not seem intrusive to the client’s freedom and personal space. These steps should also be carefully documented on the progress note. Details of this systematic approach include the activities of the client for the day and their discoveries and accomplishments over that course of time.
- Responses of Clients
The client’s responses to any intervention should be documented and these are the results of activities that they do in order to help them with their recuperation. The kinds of responses pertained to are the learnings and realizations that the client obtained upon doing tasks that are imposed by their counselors. It should also be noted that at this part, the client’s emotions towards doing the activities are tracked which may lead to unpredictable behaviors. Thus, monitoring will then be implemented and corrective interventions are done.
- Absence of Progress
There are times that the clients do not show the expected behaviors and changes to the number of steps indicated for their therapy. Likewise, the lack of progress should also be recorded and should be given immediate attention. With this, therapists and counselors must redo or change parts of the therapy program. In that way, the adverse effects of the unresponsiveness of the client to the current treatment will be prevented from progressing.
What does transference or countertransference mean?
It refers to a client’s act of transferring their feelings to another person they deemed significant to them towards their therapist.
What is Psychodynamic Therapy?
It is a way for therapists to help their clients explore and recall the events of their lives that may have led to their current behaviors and life’s perspectives. They are then empowered to change themselves in order to achieve their goals in life.
What is Metacognition?
It is an empowering way of changing one’s perspective of life. It suggests that if we have the power to observe our thoughts, we also have the power to change them.
Progress notes go beyond being a mere record of the client’s treatment experience but they most importantly tell the story of their recovery from what illness they are suffering. Hence, it should be made with a careful understanding of who they are and where they are coming from and should contain in every detail what must be done to end their suffering.
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