Clinical progress notes are written in the field of mental health to assess behaviour and progress, keep track of treatment goals and keep a written record of a session. Every mental health agency will have slightly different procedures and paperwork for writing clinical progress notes, but there are some key areas that should always be included. Progress notes are written every time an individual takes part in a session, and closing notes are written when termination of services occurs.
Write clinical progress notes as soon after a session with a client or patient as possible. It is important to be able to remember details from the session. Write them on the premises where the session took place.
Write the notes using the template or computer program designated for progress notes at the agency where you work. If self-employed, create a template for progress notes and keep the notes locked in a secure place, such as a filing cabinet with a lock.
Write important information such as the date, length of appointment, name of client or patient and your name. Include a brief summary of what took place during the session, what techniques and theories were used, whether the client had any suicidal ideations and any diagnosis.
Write down any symptoms that the individual was experiencing during the session such as lack of attention, anxiety or depressed behaviour. Include any progress made since the last session. Include information on any medications that the person is taking and whether these medications have changed.
Sign and date the form once you are finished. Make a copy for your records and place the original copy into the permanent file of the client or patient.