What most therapy progress notes include
Whatever the format, most progress notes record:
- The basics: client identifier, date, start and end time, session type (individual, couple, family, group; in person or telehealth) and who attended.
- What the client reported about their concerns and the time since the last session.
- What you observed, including any measures you gave.
- What you did: the interventions you used.
- How the client responded, and their progress toward treatment-plan goals.
- Risk: what you asked and what you found, including when there is no concern.
- The plan: next steps, homework and the next appointment.
- Your signature and credentials.
Your licensing board, agency or payer may require more, such as a diagnosis code or a statement of why treatment continues. Check their requirements.
A progress note is different from psychotherapy notes, the separate process notes some therapists keep for themselves. The two are treated differently in records rules.
One session, three formats
All examples on this page are fictional composites. They do not describe real clients.
The session: an adult client in their 30s, session 5 of treatment for social anxiety, in person, 50 minutes. Treatment goal 1: speak up at least once in each weekly team meeting. Measure: the Social Phobia Inventory (SPIN), a 17-item self-report scored 0 to 68. Each real note would also carry the client identifier, date, start and end time, session type, who attended and the clinician's signature and credentials; they are left out here to keep the examples short.
Narrative
Client attended session 5 for social anxiety. Client reported speaking once in this week's team meeting, the first time in months, and said their heart was "pounding the whole time." They declined a coworker's lunch invitation. Client was on time, made good eye contact and was anxious when describing the meeting, then more relaxed. SPIN score 38 (was 46 at intake). We reviewed the meeting using the exposure log; client rated anxiety 75 (0 to 100) before speaking and 40 afterwards, and noted that the feared outcome (being laughed at) did not happen. We planned the next steps on the exposure hierarchy. Client denies suicidal ideation. Client is making progress toward goal 1: the feared outcome did not happen, and anxiety fell after they spoke. Plan: speak twice in next week's meeting and accept one lunch invitation; log anxiety before and after. Next session in one week.
SOAP
S: Client reports speaking once in the weekly team meeting, the first time in months; "my heart was pounding the whole time." Exposure log: anxiety 75 (0 to 100) before speaking, 40 after; feared outcome (being laughed at) did not occur. Declined a coworker's lunch invitation. Denies suicidal ideation. O: On time, good eye contact. Anxious affect when describing the meeting, more relaxed later. SPIN: 38 (was 46 at intake). Exposure log completed. A: Progress toward goal 1. Reviewed the exposure log and planned next hierarchy steps with client. The absence of the feared outcome and the drop in anxiety support continued exposure work. Avoidance of informal social contact remains. No risk indicators. P: Next hierarchy steps: speak twice in next week's meeting and accept one lunch invitation. Log anxiety before and after each. Next session in one week.
DAP
D: Client reports speaking once in the weekly team meeting and declining a lunch invitation. Anxious affect when describing the meeting, more relaxed later. SPIN: 38 (was 46 at intake). Reviewed the exposure log: anxiety 75 (0 to 100) before speaking, 40 after; feared outcome did not occur. Denies suicidal ideation. A: Progress toward goal 1. The feared outcome did not happen and anxiety fell after speaking, which supports continued graded exposure. Informal social contact is still avoided. No risk indicators. P: Speak twice in next week's meeting and accept one lunch invitation; log anxiety before and after. Next session in one week.
What changes between formats: where the client's report and your observations sit (separate in SOAP, together in DAP and narrative) and how much structure the reader gets. What stays the same: the facts, the link to the goal, the risk check and the plan.
Common mistakes
- Writing the note days later. Detail fades. Write it the same day where you can.
- No interventions recorded. A note that only describes the client's week does not show what you did.
- No link to the treatment plan. Name the goal and how the client is doing against it.
- Copying last week's note forward. Each note should describe this session.
- Too much detail. Record what is clinically relevant. Long verbatim accounts rarely help the reader and can expose the client if records are shared.
FAQ
What should a therapy progress note include?
At minimum: the date and length of the session, what the client reported, what you observed, the interventions you used, the client's response, progress toward treatment goals, a risk check and the plan. Your setting or payer may add requirements.
Which progress note format is best?
The one your setting, supervisor or payer expects. SOAP separates the client's report from your observations, DAP combines them, and narrative notes give you more freedom with less structure.
How long should a therapy progress note be?
Long enough that another clinician could understand the session and continue the work. For many routine sessions, a short paragraph per section or a single paragraph in narrative form.
What is the difference between progress notes and psychotherapy notes?
Progress notes are the official record of treatment. Psychotherapy notes are a therapist's separate process notes and are handled differently under records rules.
This page is educational. Adapt the template to your licensing board, your payer and your setting.
Reframe Practice is a tool for licensed therapists, not a therapy clinic or counseling service.