7 Elements of the Best Mental Health Progress Notes
7 Elements of the Best Mental Health Progress Notes
What is a mental health progress note?
Progress notes are a form of documentation mental health practitioners, e.g., psychologists, social workers, therapists, and others use to record psychotherapy patients’ progress.
Ok, but what does that mean? Typically, that means a progress note will include:
1) Patient reported and therapist observed information about thoughts, feelings, and behaviors. These data provide both the patient and the therapist with a sense of the patient’s current experience and functioning relative to the treatment plan, and therefore a gauge of the client’s progress.
2) An analysis or assessment by the therapist of all of those data, which informs treatment.
3) Identified interventions or psychotherapy techniques used in the session.
4) Plan for what is to be done before the next session and in the next session.
Is there consensus on what a progress note needs to be?
While there will be a great deal of overlap among particular schools of psychotherapy, state licensing boards, community agencies, university counseling centers, and private practices recommend or require, there is no clear consensus. Since where you live, your mental health profession, which psychotherapy model you utilize, and where you are employed may determine what are critical elements, it is important you are thoughtful about determining what will go in your mental health progress note.
There are three common easy to use mental health progress note formats, that can efficiently cover what many insurance carriers, agencies, state licensing boards, university counseling centers, community mental health agencies, and private practices likely want you to include.
They are easy to use and even have succinct acronyms – as does almost everything in the mental health field.
BIRP
B = Behavior
Behaviors in this section can be conceptualized broadly. These will include subjective (those reported by the client) and objective (those observed or obtained by the therapist). Specifically overt motor behaviors, i.e., what the client reported they did and what the therapist sees them do in the session. Examples could include a client reporting that they left a party early because they were anxious. The anxiety too though, while an experience can be included, as can reported thoughts as behavior in this section. Some therapy models view emotions and thoughts as kinds of behavior, and the client reporting either orally or even in questionnaires what they were thinking in feeling, is in fact behavior.
I = Intervention
Interventions are what the therapist does in session to address the current signs and symptoms of the client. Interventions are psychotherapy techniques intended to reduce the therapy patient’s suffering with anxiety, depression, and other symptoms. Techniques could include cognitive rehearsal of adaptive thoughts to increase the believability of coping beliefs, a mindfulness exercise to defuse from a thought, a relaxation exercise to reduce the overactivation of the sympathetic nervous system, or assertiveness training to improve the likelihood of a close social support network.
R = Response
Responses of the psychotherapy patient to the intervention or other interactions of the therapy session can be recorded here. Did the therapy client like the mindfulness exercise, or were they resistant and make comments they thought it was too “foo-foo!” Did the therapy client become angry and think the therapist was invalidating or pushing too much, or even cold, distant, or distracted? Then any conclusions about the impact on motivation and the therapeutic relationship or alliance, as well as steps taken to repair, resolve, or overall improve the relationship and motivation can be documented here as well.
P = Plan
The plan for what comes next can include what will occur between this session and the next, as well as what will take place in the next and future psychotherapy sessions. Therapists may reference interdisciplinary or other professional referrals, e.g., therapist recommended contacting a psychiatrist for a psychopharmacological evaluation, homework or between session work to be completed before the next therapy session, and what the therapy agenda will be for the next and future sessions.
DAP
To be candid – different acronym, same stuff, i.e., same wine in new bottles. To save you time, we’ll reference the BIRP items.
D = Data
Data include both the subjective and objective information that comes from the therapy client, questionnaires (from the client or collaterals in their lives), and the therapist. This is just like Behavior in the BIRP mental health progress note.
A = Assessment
Assessment is where the therapist can document their analysis and conclusions from all of the data they have now collected. The client reported being particularly plagued by worries about being contaminated, scores went up on the Y-BOCS, during the session the therapist noticed constant fidgeting, and pressured speech. Based on that the therapist asked if the client’s anxiety overall had significantly increased this week and the client said, “Yes, I’m incredibly anxious and can’t get these thoughts out of my head!” The therapist then concluded there was a significant increase in anxiety and worries and a failure for the client’s existing coping skills to manage that level of distress.
P = Plan
Planning here would be based on the Assessment (or analysis) and is the same as the Plan described in the BIRP format above.
SOAP
The SOAP note may be the most widely used note in agencies. The good news is all of the elements have been covered in the BIRP and the DAP above. Unlike the BIRP and DAP which group subjective and objective sections together in Behavior (BIRP) or Data (DAP), the SOAP note breaks them into two separate sections. Yes, you guessed it, Subjective and Objective.
Then Assessment and Plan are the same as we have above.
S = Subjective
Subjective information about situations or triggers, thoughts, feelings, behaviors, sensations or any other kind of experiences or episodes reported by the therapy client can be recorded in the Subjective section of the SOAP note.
O = Objective
Likewise, all of that same information that the therapist observes or gathers from using any form of Routine Outcome Measures (ROMs) can be recorded in the Objective section of the SOAP note.
A = Assessment
Assessment or analysis in the SOAP note, again are identical to that of assessment in the DAP note. This is where the therapist analysis any data they have and make conclusions that will help formulate the plan for what comes next and also possibly revise the existing case conceptualization and treatment plan.
P = Plan
The Plan section in the SOAP note is the same as it is in both the BIRP Progress Note and the DAP Progress Note.
What does an evidence-based progress note look like and is it the best?
Now, if your aim is to provide the best therapy to your psychotherapy clients, and you view evidence-based practice as the method for that quality based care, there are seven specific items you may want to include in a progress note. There is a great deal of scientific support for what we know enhance the effectiveness of psychotherapy. Many of these exist across various treatment modalities or theoretical orientations.
Here are seven elements you can carry out during a therapy session and document in a progress note that can help you provide high quality evidence-based care to your psychotherapy clients.
1) Collaboratively set an agenda. Discuss and together identify the agenda items that will be most beneficial for the therapy session.
2) Review the homework (or between session work). Check in with the client to see which homework assignments were completed, which weren’t, and then if not, what feelings came up about not doing them and possibly figuring out together why they weren’t completed and how to handle moving forward, i.e., ways to increase motivation, overcome challenges to the work, or assign different or less homework.
3) Look at and discuss Routine Outcome Measures (ROMs) or other progress metrics. This allows the therapist greater understanding of the current experiences, stressors, level of functioning, and relationship health of the client in the context of the Case Conceptualization and Treatment Plan. By understanding the client’s current level of suffering and satisfaction greater empathy, options for enhancing the therapeutic alliance, and more effective treatment all become more likely.
4) Record the symptoms and signs assessed by the ROMs and any reporting by the client in the session.
5) Review the Case Conceptualization and Treatment Plan with an emphasis on any discrepancies among the current client experience and what would be expected based on the Case Conceptualization and Treatment Plan. Revise either as necessary and make note of what and why those changes were made in the Mental Health Progress Note.
6) Select the most effective evidence-based technique now that you have either revised or reinforced your existing Treatment Plan with the information you have just collected and recorded.
7) Together discuss what work (homework or between session work, whatever flavor you like) could be done before the next session that can help the client reduce any suffering, enhance existing strengths, improve relationships, increase self-efficacy, strengthen social support, or improve motivation.
Wow – and all in 38 to 53 minutes! Oh, and not only do you do it, but you want to record that you did it.
That’s where My Best Practice comes in. Our Electronic Health Record (EHR) was the first designed for evidence-based practice. It streamlines this process, automating everything possible you need to do all of that with minimal time. It collects much of the information for you automatically, reminds you what to do, and records most of it without you doing anything right in your progress note. And it lets you use one of our notes, or customize your own.
My Best Practice helps you practice better by letting you focus on the client.
