Chapter 6:

Progress Notes
Case Documentation in Counseling and Psychotherapy
Diane R. Gehart

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Step 4: Document It
• A Breadcrumb Trail
• Documenting where you’ve been and what you have done
• Progress Notes
• An official record of what happens in each meeting with the
client

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ON A DIFFERENT NOTE: PROGRESS VS.
PSYCHOTHERAPY NOTES
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Progress vs. Psychotherapy Notes
• Progress Notes: The “Official” Medical File:
• Shared with other medical professionals, clients (upon written
request), and/or in response to subpoenas
• Specific requirements from Third-party payers
• Psychotherapy Notes: Counselor’s Case Conceptualization File
• Kept separate and private with few guidelines
• Distinct property of the counselor; clients do not have rights to
these records

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PROGRESS NOTES

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Progress Notes
• Ethical Mandates of HIPAA Progress Note
• Maximize client privacy
• Documenting competent treatment that conforms to professional
standards of care.
• Counselors Document
• Progress and setbacks related to psychiatric symptoms
• Interventions used to treat those symptoms
• The client response to those treatments
• Crisis Situations
• Write detailed notes on crisis situations

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Progress Note Ingredients
• Client Identification
• Time
• Who
• Progress and Symptoms
• Assessment and Crisis:
• Interventions
• Plan
• Signature

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TYPES OF PROGRESS NOTES

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Progress Notes Types
• SOAP Notes
• DAP Notes
• BIRP Notes
• HIPPA Progress Note

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SOAP Notes
• Subjective Observations
• Description of client’s narrative and/or reported symptoms.
• Objective Observations
• Counselor’s observations, test results, findings from physical
examination, vital signs.
• Assessment
• Summary of symptoms, assessment, and diagnosis; differential
diagnosis considerations.
• Plan
• Plan to treat listed symptoms, including instructions and
medications given to client.

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DAP Notes
• Data
• What happened or was said in session, interventions, clinical
observations, test results, symptoms, stressors, etc.
• Assessment
• Assessment of symptoms, outcome of current session and overall
course of counseling, treatment plan goals/objectives being met,
areas needing more work, areas of progress, etc.
• Plan
• Homework, interventions for next session, timing of next
sessions, changes to treatment plan; progress made

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BIRP Notes
• Behavior
• A behavioral description of symptoms that typically includes
duration, severity, and frequency
• Intervention
• A description of interventions used in session
• Response
• Description of client response to the interventions
• Plan
• Plan for next session and/or changes to the treatment plan

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The All-Purpose HIPAA
Progress Note
• Initial information: client #, date, time, length, persons
present, CPT Billing codes
• Symptom progress and Interventions
• Client response
• Plan and any Crisis issues
• Consultation & Supervision, Collateral Contacts, professional
signature

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HOW TO COMPLETE A PROGRESS NOTE

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Complete Progress Notes (Slide 1 of 5)
• Client #
• Client names should never be put on file labels or progress notes
• Date/Time/Session Length
• Start each note with the date of the session; time session started;
and length of session
• Persons Present
• AF: Adult Female: If more than one, add age (AF34; AF62) or
simply AF1 and AF2
• AM: Adult Male: If more than one, add age (AM24; AM 58) or
AM1 and AM2
• CF#: Child Female plus age (e.g. CF8=eight-year-old girl)
• CM#: Child Male plus age (e.g. CM8=eight-year-old boy)

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Complete Progress Notes (Slide 2 of 5)
• CPT Billing Codes
• CPT (Current Procedural Terminology) codes identify what type of
service was provided
• Examples:
• 90791: Psychiatric diagnostic evaluation (generally used for the first
session)
• 90832: Psychotherapy, 30 minutes with patient and/or family
member
• 90834: Psychotherapy, 45 minutes with patient and/or family
member (used for standard 45-50 minute session)
• 90845: Psychoanalysis
• 90846: Family psychotherapy, 45-50 minutes
• 90847: Family psychotherapy, conjoint psychotherapy with patient
present, 45-50 minutes
• 90849: Multiple-family group psychotherapy
• 90853: Group therapy (other than multiple-family group)
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Complete Progress Notes (Slide 3 of 5)
• Symptom Progress
• The duration, frequency, and severity of symptoms from session
to session
• Behavioral: Describe symptoms in behavioral terms when possible
• Psychiatric: Use psychiatric terms as much as possible
• Measurable: Include duration, frequency, and severity whenever
possible
• Interventions
• Identify which interventions the counselor used to help the client
address problems
• Examples:
• Used solution-focused scaling to identify steps to reduce depression
over next week.
• Used empty-chair technique to practice sharing feelings with spouse.
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Complete Progress Notes (Slide 4 of 5)
• Client Response
• Whether or not they responded well or not to interventions and
what did and did not work
• Examples:
• Client receptive to reframe related to work issues; less receptive to
reframe of pattern related to relationship
• Client actively engaged in empty-chair technique; optimistic could
employ at home
• Plan
• Describes plan for next session and/or plans to modify treatment
plan.
• Will bring in partner to next session.
• Follow up on journal assignment: letter to future self.
• Crisis Issues
• The assessment process and data used to support conclusions
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Complete Progress Notes (Slide 5 of 5)
• Consultation and Supervision
• Document recommendations and/or information, especially
regarding ethical and legal issues
• Collateral Contacts
• Contact another professional or family member regarding a
client, such as a teacher, physician, psychiatrist, social worker,
parent, etc
• Signature
• Sign the progress note by hand (no initials)
• Indicate license status

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Final Notes on Notes
• Immediately Write Notes Following The Session
• Progress Notes Belong In A Locked File

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QUESTIONS FOR PERSONAL
REFLECTION AND CLASS DISCUSSION
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Reflection Questions
• Do you think the increased standardization of progress notes
is helpful or unhelpful? Constraining or reassuring?
• What surprises you most about the common ingredients in a
progress note? Do you think something is missing?
• How might documenting mental health symptoms from week
to week help the counseling process? How might it limit the
process?

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