A Simple Approach to Progress Notes

Since people keep asking me to share my progress note format, I thought I should put it here where everyone can access it.

But why?

When I started out in private practice, I’d make notes on a paper notebook and then type them into my EHR. That took a lot of time, and it was annoying to not have my notes on hand for subsequent sessions. Then I realized there was no reason for me to be entering my notes into my EHR, and that I could just write them into a paper template that I printed out.

Two options

There are two versions, and they’re both designed to capture the items you might run into most frequently, and enable you to use checkboxes and brief statements to capture notes for your sessions. The first has more detail than the second.

In both cases, the idea is that if you were ever asked to produce notes for insurance, you could easily convert these notes into something more complete. For example, if you checked “CBT” under Interventions and wrote “address black and white thinking” in the Goals section you could turn that into “Used cognitive behavioral therapy approaches with the client to address black and white thinking” if you were asked to provide notes to a third party.

First notes template:

This template takes up one whole page and has sections that I found useful. However, after a while I realized I wasn’t using some of these items at all, or they were redundant, so I came up with the second template.

Second, shorter notes template

This template is more compact and fits two sessions onto one sheet of paper.

Here are the files!

Now, what you’ve all been waiting for, the files themselves!

Click here for the first notes template.

Click here for the second, more compact notes template.

Let me know what you think of these in the comments below! Is this helpful? Do you use a similar system?