As a healthcare professional, you know that progress notes are the backbone of patient care documentation. Yet, crafting clear, concise, and compliant progress notes can be a daunting task. Many practitioners struggle with balancing thoroughness and efficiency, often leading to incomplete or ineffective documentation.

This comprehensive guide to progress notes examples will help you transform your documentation process. We’ll explore various types of progress notes, provide real-world examples across different healthcare specialties, and share best practices that will streamline your workflow. Whether you’re a seasoned professional looking to refine your skills or a newcomer seeking to establish good habits, this article will equip you with the knowledge and tools to create effective progress notes with confidence.

Let’s dive in and unlock the secrets to mastering progress notes!

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What Are Progress Notes?

Progress notes are essential clinical documentation used in healthcare, therapy, and counseling to record client interactions, observations, and treatment progress. These notes serve multiple purposes:

1. Tracking patient progress
2. Facilitating communication among healthcare team members
3. Supporting continuity of care
4. Meeting legal and regulatory requirements
5. Justifying billing and insurance claims

Effective progress notes contribute to improved patient outcomes by providing a comprehensive record of the treatment journey and facilitating informed decision-making among healthcare professionals.

Types of Progress Notes

There are several types of progress notes, each serving a specific purpose in healthcare documentation. Let’s explore the most common types:

1. SOAP Notes

SOAP (Subjective, Objective, Assessment, Plan) notes are widely used across various healthcare disciplines. They provide a structured format for organizing patient information.

Section	Description	Example
Subjective	Patient’s reported symptoms and concerns	“Patient reports persistent headache for the past 3 days”
Objective	Observable, measurable data	“Blood pressure: 130/85 mmHg, Temperature: 98.6°F”
Assessment	Healthcare provider’s analysis and diagnosis	“Tension headache likely due to stress”
Plan	Treatment plan and follow-up instructions	“Prescribed ibuprofen 400mg every 6 hours as needed”

2. DAP Notes (Data, Assessment, Plan)

DAP (Data, Assessment, Plan) notes are similar to SOAP but combine Subjective and Objective into Data.

Section	Description	Example
Data	Combined subjective and objective information	“Client exhibits signs of depression, including lack of motivation and sleep disturbances”
Assessment	Healthcare provider’s analysis and diagnosis	“Depression severity is moderate”
Plan	Treatment plan and follow-up instructions	“Initiate cognitive-behavioral therapy and consider medication evaluation”

3. DART Notes

DART (Data, Action, Response, Treatment) notes are commonly used in psychiatric and mental health settings.

Section	Description	Example
Data	Information gathered from patient or observations	“Patient reports increased anxiety in social situations”
Action	Interventions or treatments provided	“Introduced breathing exercises for anxiety management”
Response	Patient’s reaction to the interventions	“Patient reported feeling calmer after practicing exercises”
Treatment	Ongoing or future treatment plans	“Continue practicing breathing exercises, consider group therapy”

4. Focus Notes

Focus notes concentrate on a specific problem or aspect of a patient’s care. They are particularly useful when addressing a single issue in detail.

Section	Description	Example
Problem	Specific issue being addressed	“Chronic lower back pain”
Details	Relevant information about the problem	“Pain intensity: 7/10, worse with prolonged sitting”
Action	Steps taken to address the problem	“Prescribed physical therapy, 2 sessions per week for 6 weeks”
Outcome	Expected or observed results	“Reassess pain levels and mobility in 3 weeks”

5. Narrative Notes

Narrative notes provide a chronological account of a patient’s visit or treatment session. They offer more flexibility in recording information but may lack the structure of other note types.

Section	Description	Example
Introduction	Brief overview of the session	“Client arrived on time for follow-up appointment”
Main Content	Detailed account of the session	“Expressed concerns about recent weight gain. Discussed dietary habits and physical activity.”
Conclusion	Summary and next steps	“Recommended balanced diet and regular exercise.

There are also several other progress note formats used in various healthcare settings:

• DAT (Data, Assessment, Treatment)
• BIRP (Behavior, Intervention, Response, Plan)
• GIRP (Goal, Intervention, Response, Plan)
• PIRP (Problem, Intervention, Response, Plan)
• RIFT (Reason, Intervention, Findings, Treatment)
• CARE (Context, Action, Response, Evaluation)
• STOP (Status, Treatment, Outcome, Plan)
• MINT (Medical Issue, Intervention, Next Steps, Teaching)
• FORT (Focus, Objective, Response, Treatment)

These formats may be less standardized and more specific to certain specialties or institutions. The choice of note format often depends on the healthcare setting, specialty, institutional preferences, and the specific needs of the patient or treatment program. Healthcare providers should familiarize themselves with the preferred format used in their practice setting to ensure consistent and effective documentation.

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Progress Notes Examples by Healthcare Specialty

Let’s explore specific examples of progress notes for various healthcare specialties:

– Physical Therapy SOAP Progress Note Example

Patient: Jane Doe

Date: 07/27/2024

Time: 2:00 PM

S:

The patient reports decreased pain in the right knee (3/10) compared to last session (6/10). States she has been consistently doing her home exercises.

O: 

– Right knee ROM: Flexion 110°, Extension 0°

– Strength: Quadriceps 4/5, Hamstrings 4/5

– Gait: Improved, minimal limping observed

A:

The patient showing good progress with increased ROM and strength. Pain levels decreasing as expected.

P: 

1. Continue with the current exercise program

2. Increase resistance for quad strengthening exercises

3. Begin balance training exercises

4. Schedule follow-up appointment in 1 week

Therapist: John Smith, PT, DPT

– Mental Health Counseling DAT Progress Note Example

Client: Michael Johnson

Date: 07/27/2024

Time: 3:30 PM

Data:

• The client identified and challenged three negative thought patterns
• The client reported anxiety level of 6/10, down from 8/10 in the previous session
• The client successfully used deep breathing technique twice this week to manage panic symptoms
• Intervention used: Cognitive Behavioral Therapy (CBT) – Thought challenging exercise

Assessment:

• The client shows progress in identifying and challenging negative thought patterns
• Anxiety levels have decreased since the last session
• The client is effectively using learned coping strategies (deep breathing) outside of sessions
• Continued focus on cognitive restructuring and introduction of additional coping techniques may further benefit the client

Plan:

1. Continue CBT exercises focusing on cognitive restructuring
2. Introduce mindfulness meditation techniques
3. Assign homework: Daily thought journal
4. Next appointment scheduled for 08/03/2024

Therapist: Sarah Brown, LMHC

– Occupational Therapy Narrative Progress Note Example

Patient: Robert Chen

Date: 07/27/2024

Time: 3:15 PM

Mr. Chen, a 58-year-old male recovering from a right-sided stroke, attended his occupational therapy session today. He reported feeling more confident with his morning routine but expressed frustration with buttoning his shirts.

Upon assessment, Mr. Chen demonstrated improved grip strength in his right hand (now 3+/5, up from 2/5 last week). His fine motor skills show progress, as evidenced by his ability to manipulate smaller objects such as a pen and utensils with increased control. However, he still struggles with more complex tasks requiring bilateral coordination.

We focused today’s session on activities of daily living (ADLs), particularly dressing skills. Mr. Chen practiced buttoning and unbuttoning a shirt with various sized buttons, starting with larger ones and progressing to smaller sizes. He showed determination and was able to complete the task with the larger buttons independently after several attempts. We also worked on energy conservation techniques and adaptive strategies for dressing.

Mr. Chen’s balance while standing has improved, allowing him to maintain his position while manipulating clothing for about 2 minutes before needing to sit. This is a significant improvement from last week when he could only stand for 30 seconds during similar activities.

For homework, Mr. Chen will continue practicing buttoning/unbuttoning with his affected hand and will attempt to incorporate more bilateral activities in his daily routine, such as folding laundry.

Our next session will focus on kitchen activities, particularly meal preparation tasks that require bilateral hand use. We will also continue to work on fine motor skills and increase the complexity of dressing activities.

Mr. Chen remains motivated in his rehabilitation journey and is making steady progress towards his goals of independent self-care and return to work as a high school teacher.

Occupational Therapist: Emily Taylor, OTR/L

– Dental Progress SOAP Note Example

Patient: Robert Williams

Date: 07/27/2024

Procedure: Follow-up after root canal treatment on tooth #19

S:

The patient reports no pain or discomfort. No sensitivity to hot or cold.

O: 

– Visual examination: Temporary filling intact

– Percussion test: Negative

– Palpation: No tenderness in surrounding tissues

– Radiograph: Shows adequate root canal filling

A:

Healing progressing as expected post-root canal treatment

P: 

1. Schedule for permanent crown preparation in 2 weeks

2. Reinforce oral hygiene instructions

3. Advise the patient to return if any pain or swelling occurs

Dentist: Dr. Emily Chen, DDS

– Mental Health Counseling BIRP Progress Note

Client: Emma Rodriguez

Date: 07/27/2024

Time: 2:00 PM

Behavior:

The client presented with visible signs of anxiety (fidgeting, rapid speech). Reported experiencing intrusive thoughts about work performance and difficulty sleeping. Stated she had two panic attacks in the past week, each lasting about 15 minutes.

Intervention:

1. Utilized Cognitive Behavioral Therapy (CBT) techniques to identify and challenge negative thought patterns related to work performance.
2. Taught progressive muscle relaxation (PMR) technique as a tool for managing anxiety and improving sleep.
3. Explored and validated client’s feelings about recent work stressors.

Response:

The client was receptive to CBT techniques and actively participated in identifying negative thought patterns. She expressed relief after challenging these thoughts and reported feeling “less overwhelmed.” The client successfully practiced PMR during the session and reported feeling more relaxed afterward. Emma showed interest in continuing to use these techniques outside of therapy.

Plan:

1. Continue CBT work, focusing on work-related anxiety.
2. Assign homework: Practice PMR daily and log results.
3. Introduce sleep hygiene techniques in the next session.
4. Discuss the possibility of a medication evaluation with a psychiatrist.
5. Next appointment scheduled for 08/03/2024.

Therapist: Dr. James Wilson, PhD

– Oncology Progress SOAP Note Example

Patient: Thomas Anderson

Date: 07/27/2024

Time: 10:30 AM

S:

The patient reports feeling fatigued (6/10) and experiencing occasional nausea after chemotherapy sessions. Denies fever or severe pain. His appetite has improved slightly since the last visit.

O:

• Vitals: BP 118/76, HR 82, Temp 37.1°C, RR 16
• Weight: 68 kg (stable from last visit)
• Physical exam: No new lymphadenopathy, lungs clear to auscultation
• Lab results: WBC 3.8, Hgb 10.2, Platelets 115

A: Stage III colon cancer, undergoing cycle 3 of FOLFOX regimen. Experiencing expected side effects, but overall tolerating treatment well.

P:

1. Continue current chemotherapy regimen
2. Prescribe antiemetic for breakthrough nausea
3. Encourage increased fluid intake and small, frequent meals
4. Schedule next chemotherapy session in 2 weeks
5. Order CBC prior to next session

Oncologist: Dr. Lisa Wong, MD

– Emergency Medicine DART Progress Note Example

Patient: Sarah Thompson

Date: 07/27/2024

Time: 11:45 PM

D (Database):

• 32-year-old female presenting with severe abdominal pain
• Vitals: BP 130/85, HR 98, RR 20, Temp 37.8°C, SpO2 99% on RA
• Pain score: 8/10, localized to right lower quadrant
• Last menstrual period: 2 weeks ago
• No history of similar pain, no recent travel
• Physical exam: Tenderness in RLQ, positive rebound tenderness, negative Rovsing’s sign

A (Assessment):

• Suspected acute appendicitis
• Differential diagnoses: Ovarian cyst rupture, ectopic pregnancy, pyelonephritis

R (Response/Results):

• CBC: WBC 14,500 with left shift
• Urinalysis: negative for infection
• β-hCG: negative
• CT scan: enlarged appendix with surrounding inflammation

T (Treatment/Plan):

1. NPO status
2. IV fluids: Normal saline 1L bolus, then 100 mL/hr
3. Pain management: Morphine 4mg IV
4. Antibiotic: Ceftriaxone 1g IV
5. Consult surgery for appendectomy
6. Reassess pain and vitals q2h

Emergency Physician: Dr. James Wilson, MD

– Nephrology Progress Focus Note Example (FOCUS Format)

Patient: James Brown

Date: 07/27/2024

Time: 2:30 PM

Problem:

Chronic Kidney Disease (CKD) Stage 4 secondary to diabetic nephropathy

Objective/Details:

• A 62-year-old male with 20-year history of type 2 diabetes
• Current complaints: fatigue, decreased appetite, intermittent nausea
• Medications: Insulin glargine, Lisinopril, Atorvastatin, Furosemide
• Vitals: BP 142/88, HR 78, RR 16, Temp 36.7°C, SpO2 97% on room air
• Physical exam:
  • General: Alert, oriented, appears fatigued
  • Cardiovascular: Regular rate and rhythm, no murmurs
  • Respiratory: Clear to auscultation bilaterally
  • Extremities: 1+ pitting edema bilaterally
• Lab results:
  • Creatinine: 3.8 mg/dL (increased from 3.5 mg/dL 3 months ago)
  • eGFR: 22 mL/min/1.73m² (decreased from 25 mL/min/1.73m² 3 months ago)
  • BUN: 48 mg/dL
  • Potassium: 5.1 mEq/L
  • Hemoglobin: 10.2 g/dL
  • HbA1c: 7.8%

Action:

1. Adjust medication:
   • Increase Furosemide to 80 mg daily to manage fluid retention
   • Add Sodium bicarbonate 650 mg twice daily for metabolic acidosis
2. Refer to a dietitian for low-protein, low-potassium diet education
3. Initiate erythropoietin therapy for anemia management
4. Educate the patient on the importance of glycemic control; consult endocrinology for diabetes management optimization
5. Discuss renal replacement therapy options and initiate pre-dialysis education
6. Schedule vascular surgery consult for potential AV fistula creation

Outcome:

• Patient demonstrates understanding of CKD progression and the potential need for dialysis in the near future
• Agreed to follow up with dietitian and attend pre-dialysis education classes
• Will return in 2 weeks for repeat labs and reassessment
• Emphasized importance of medication adherence, diet modifications, and glycemic control
• Provided sick-day management instructions and when to seek immediate medical attention

Nephrologist: Dr. Sarah Chen

Certainly. Here’s a GIRP Progress Note example for a physical therapy session:

– Physical Therapy GIRP Progress Note

Client:

Sarah Adam

Date: 07/27/2024

Time: 2:00 PM

Goal:

Improve right knee mobility and strength following ACL reconstruction surgery to enable return to recreational soccer.

Intervention:

1. Performed manual therapy techniques to improve knee flexion range of motion (ROM).
2. Guided patient through a series of closed kinetic chain exercises focusing on quadriceps and hamstring strengthening.
3. Introduced balance and proprioception exercises using a wobble board.
4. Applied kinesiology tape to reduce swelling around the knee joint.

Response:

The patient tolerated manual therapy well, reporting decreased stiffness post-treatment. Right knee flexion ROM improved from 100 to 110 degrees. Sarah successfully completed 3 sets of 10 repetitions for each strengthening exercise with minimal compensatory movements. During balance exercises, the patient showed improved stability compared to the previous session but still required occasional upper extremity support. Sarah reported feeling “more confident” in her knee stability post-session.

Plan:

1. Progress closed kinetic chain exercises by increasing repetitions and adding resistance.
2. Continue manual therapy to further improve ROM, targeting 120 degrees of knee flexion.
3. Advance balance exercises by incorporating dynamic movements and reducing upper extremity support.
4. Introduce light jogging on a treadmill if ROM and strength goals are met in the next session.
5. Assign home exercises: Straight leg raises, wall squats, and single-leg balance practice.
6. Next appointment scheduled for 08/03/2024.

Therapist: Mark Johnson, DPT

– Pediatric Progress SOAP Note Example

Patient: Emily Johnson

Date: 07/27/2024

Time: 2:45 PM Age: 4 years

S:

Mother reports Emily has had a fever for 2 days, accompanied by a sore throat and decreased appetite. No vomiting or diarrhea. Sleep has been disturbed due to discomfort.

O:

• Vitals: Temp 38.5°C, HR 110, RR 24, BP 90/60
• Weight: 16.8 kg (50th percentile)
• Physical exam:
  • Throat: Erythematous with enlarged tonsils
  • Neck: Palpable, tender cervical lymph nodes
  • Lungs: Clear to auscultation bilaterally
  • Skin: No rash observed

A:

Acute pharyngitis, likely viral etiology. Differential includes strep throat.

P:

1. Perform rapid strep test
2. Advise supportive care: rest, fluids, and acetaminophen for fever and pain
3. Educate on signs of worsening condition
4. Follow up in 2-3 days if symptoms persist or worsen
5. If the strep test positive, will prescribe appropriate antibiotic

Pediatrician: Dr. Michael Brown, MD

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Best Practices for Writing Progress Notes

To ensure your progress notes are effective and compliant, follow these best practices:

• Be objective and factual
• Use clear, concise language
• Avoid jargon and abbreviations
• Include relevant details only
• Document promptly after each session
• Maintain patient confidentiality (e.g., HIPAA compliance)
• Use proper grammar and spelling
• Sign and date all entries
• Follow standardized formats (e.g., SOAP, DAP)
• Develop a consistent shorthand system
• Utilize electronic health record (EHR) systems
• Practice active listening during patient interactions
• Periodically review and update your documentation process
• Tailor notes to your specific field of practice
• Be aware of legal and ethical requirements in your jurisdiction
• Regularly train on documentation best practices
• Consider the potential audience (e.g., other healthcare providers, legal professionals)
• Document any unusual circumstances or deviations from standard procedures

Common Mistakes to Avoid in Progress Notes

Be aware of these common pitfalls when writing progress notes:

• Lack of specificity
• Overuse of subjective language
• Incomplete documentation
• Illegible handwriting (for paper-based notes)
• Copying and pasting without updating information
• Including non-relevant personal opinions
• Failing to document informed consent discussions
• Using inappropriate abbreviations or acronyms
• Inconsistencies between different sections of the note

The Role of Technology in Progress Notes

Modern healthcare practices are increasingly adopting technology to improve the efficiency and accuracy of progress note documentation. Practice management solutions like Yocale offer integrated tools for scheduling, client management, and digital forms, which can significantly streamline the documentation process.

Benefits of using technology for progress notes include:

• Improved legibility and organization
• Enhanced accessibility for authorized team members
• Automated reminders for timely documentation
• Integration with other practice management functions
• Easier compliance with regulatory requirements

Conclusion

Mastering the art of writing effective progress notes is essential for healthcare professionals across all specialties. By understanding the various types of progress notes, following best practices, and leveraging technology, you can create comprehensive and accurate documentation that enhances patient care and supports your practice’s success.

Remember that progress notes are not just a legal requirement but a vital tool for providing high-quality, continuous care to your patients. As you refine your documentation skills, you’ll find that well-written progress notes can significantly improve communication among healthcare team members and contribute to better patient outcomes.

By implementing the strategies and progress notes examples provided in this guide, you’ll be well-equipped to create clear, concise, and informative progress notes that meet both professional standards and legal requirements.

FAQs

References

• How to write SOAP notes, Headway,
  https://headway.co/resources/soap-note
• Medical Necessity: A Therapist’s Guide to Utilization Review, Authorizations & Documentation, Mentalyc,
  https://www.mentalyc.com/blog/medical-necessity-documentation-utilization-review-and-authorizations
• Streamlining the Process of Writing Nursing Progress Notes in 5 Key Steps, Shiftcare,
  https://shiftcare.com/blog/streamlining-process-writing-nursing-progress-notes
• Ethical considerations for progress notes: What to leave in, what to leave out, Rula,
  https://www.rula.com/blog/ethical-considerations-progress-notes/