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Compliance and documentation

How to write progress notes

Progress notes are the core piece of documentation a provider should write after each client session, but it’s more than just a record of what happened.

December 21, 2023 • Updated on July 24, 2026

17 min read

Progress notes are aptly named: It’s a documentation of each session with your client where you share the progress you’re making on your treatment goals. Specifically, the treatment goals you aligned on in your treatment plan.

Simple, right? Not always, when you’re navigating insurer requirements and billing standards. 

“I often hear from providers I work with that the concept of progress notes is ‘easy,’ but writing them in a compliant way is the hard part,” says Innocent Turner, a LCSW in Delaware.

If the “rules” for writing compliant progress notes are confusing and vague, that’s because they’re left open for you to step in as the expert.

Other than following the advice in this article (or using a great template), Turner recommends a quick gut check. 

Read your progress notes back to yourself and reflect: Does this accurately portray what happened? Or is there an element of treatment that didn’t make it onto the page? If you feel like you’ve forgotten something, you probably did, but you can always figure out a way to include it. 

This guide will help you understand the purpose of progress notes, what to include in your session documentation, and helpful templates and examples to get you started.

Key takeaways

  • A progress note should be created after each session, capturing relevant details of that appointment while also contributing to a narrative about the client’s progress over time. 
  • Progress notes can follow various formats — but they should always include basic session details, information about the client’s mental state and progress, a risk assessment, and plans for future treatment.
  • Headway’s AI-assisted notes, templates, and more makes compliant therapy documentation easy.

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What are therapy progress notes?

Progress notes are the core piece of documentation a mental health care provider should write after each session with a client, but it’s more than just a record of what happened in the session. Progress notes keep a record of the client's progress and the care you provide.

“When someone reads a note, they need to understand how your patient presented, what's going on with them right now, how you helped them, and how they received that help,” says Innocent Turner, LCSW and Headway’s Clinical Strategy Lead. “And if those questions are answered for the most part, you’re good.”

It’s also important that clear continuity of care is documented: While each note should lead into the next, each note should also stand alone, demonstrating a clear and comprehensive story of the client's progress through treatment.

You don’t need to include everything your client said in your progress notes, only what pertains to their treatment. If they spend the first 5 minutes complaining about their in-laws, don’t worry about capturing that in your documentation. 

The 3 essential types of clinical documentation

A complete patient chart contains three core pieces of clinical documentation: an intake assessment, treatment plan, and progress notes.

Think of these as the “golden thread”: Your intake note should inform your treatment plan, and your treatment plan goals and objectives should be reflected in each progress note. 

Here are the key details of the different types of documentation:

1. An intake assessment (intake note) should be created when initiating a treatment relationship with a client, and serve to document their current state and past experiences with mental healthcare.

2. A treatment plan establishes objectives and monitors progress. The plan includes a diagnosis and clearly establishes medical necessity for treatment.

3. Progress notes should demonstrate a clear and comprehensive story of the client’s progress through treatment. Clear continuity of care is important — each note should lead into the next but also stand alone.

Clinical documentation is a staple of any mental healthcare practice — it’s used to clarify the purpose of your sessions, justify the billing code used, and demonstrate a good picture of the patient’s current mental state.

These standards are outlined by the American Medical Association (AMA), Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA), commercial insurers, and other regulatory agencies.

Your license or a particular insurer may have even stricter requirements than those set forth here.

6 requirements for progress notes

Your progress notes need to contain the following details in order to effectively capture the progress you’re making with the client towards their goals. 

1. Session details

These easy-to-note facts are required for all documentation, including your progress notes:

  • Start and stop time
  • Place of service: For telehealth sessions, include the client's location (for example: “home” or “office,” as well as a statement that the session was conducted via a HIPAA-compliance audio/visual platform)
  • Date of service
  • Patient name and date of birth
  • Provider name and credentials

2. Person-centered details

Person-centered details are session-specific information that paints a helpful picture of the client's mental state and feelings, in their own words. Infusing specificity into your notes — such as the use of quotations from your client — helps insurers verify that the session was unique and veritable, and that you didn’t simply copy and paste from a previous session. 

3. Patient-centered observations

Your notes should reflect a clinical assessment of your client’s current mental state in order to portray the full picture of their symptoms, diagnosis, and treatment. As a guide, each progress note should include at least three components of the mental status exam, such as descriptions of the patient’s appearance, behavior, alertness, reasoning, or mood.

4. Progress towards goal(s)

Make sure you identify progress towards the goal(s) outlined in your treatment plan, including whether the client made progress, regressed, or stayed about the same. Insurers review this item frequently; it's one of the most commonly missed. If you need to update the treatment plan, say that too. This will support the CPT code you're using and offer clarity if treatment goals change frequently (as they sometimes do).

5. Risk assessment

Because this is a sensitive area, it's especially important to clearly and completely document any risks in your progress note — it must also be unique to each session. Documentation of risk can be simple such as "client denies all areas of risk." That said, if you identify a risk, you are required to identify the client's risk level and create and document a safety plan. In these cases, you don't need to document the safety plan in the progress note itself, but you do need to include a note that the safety plan was created and the client agreed to it. For example, you might write "safety plan was discussed and reviewed with client."

6. Clinical path forward

Progress notes should outline the evidence-based practice used in the session, and comment on any changes in modality. You might also include any skills that may be helpful for clients to practice to help manage or reduce their symptoms, and why it would be helpful in reducing their symptoms.

Types of progress notes

Because progress notes are required for every session through insurance, it’s helpful to leverage a template to complete your notes quickly and comprehensively.

Three of the most common progress note templates include:

  • SOAP notes: Subjective, Objective, Assessment, Plan. This format allows the provider to document their observations of the client and the session, and how they’re approaching the care plan. This is a popular type of template for talk therapy, especially used by licensed clinical social workers. 
  • DAP notes: Data, Assessment, and Plan. These are similar to SOAP notes, but condense the subjective and objective sections into a single reflection of “data.”
  • BIRP notes: Behavior, Intervention, Response, and Plan. These notes help the provider reflect on the specific problem, or behavior, that’s being addressed in the session, then document what they tried and how it was received by the client.
  • GIRP notes: Goals, Intervention, Response, Plan. These notes are a good fit for goal-oriented styles of therapy, such as cognitive behavioral therapy.
  • PIE notes: Problem, Intervention, Evaluation. Short, efficient, and focused, PIE notes are a good choice for clinicians looking to get notes done fast.

Progress note example: SOAP note

Here’s an example of a progress note that meets most insurance carriers’ expectations for this type of clinical documentation. It follows the SOAP note template:

  • Subjective: A provider's own observations as well as the client's stated reasons for seeking care. Can include general references to the client's likely emotional state and the provider's summary of presenting problems.
  • Objective: References to specific and measurable elements from the session, such as physical appearance and the client's progress toward goals and modalities used during the session.
  • Assessment: A set of conclusions based on the provider's professional synthesis of both subjective and objective observations.
  • Plan: Next steps for the client, based on the provider's assessment, such as when the next session will take place, and what updates may be needed for the treatment plan.


Notice how it contains all six of the primary requirements for a compliant note.

Client Full Name: Katie Client
Client Date of Birth: 9/9/1999

Date of Service: 3/08/2023
Exact start time and end time: 10:23 am – 11:20 am: 57 mins

Session Location: Telehealth, patient provided consent to telehealth, service performed on HIPAA compliant software

Subjective notes:
Katie presents today’s session feeling “depressed.” She states that her mood has been “getting worse.” She reports that she has been struggling to get out of the house to enjoy social events that she is actually interested in, then becomes more frustrated with herself. She describes an increase in sleep issues, both difficulty falling asleep and staying asleep. Katie says that she “just wants to be better.” Katie continues to endorse low energy, loss of interest in activities, difficulty sleeping, and feelings of guilt, although she is not able to express the source of her guilt.

Objective notes:
Therapist helped Katie process her feelings, provided in depth psychoeducation on guilt and how it relates to depression. Katie’s mood throughout the session was low, flat affect, her speech is low volume and soft. Therapist used the CBT triangle in session to assess Katie’s ability to identify patterns in behavior and thoughts. Katie required extensive guidance to understand the concept of the thought triangle. Therapist explored her feelings of guilt at length, and used socratic questioning to fully engage with past experiences that may be triggering guilt/shame. Therapist helped Katie process how her feelings influence her behavior (CBT triangle) and discussed in depth behavioral patterns that potentially are increasing her depressive symptoms.

Assessment:
Katie continues to struggle with depressive symptoms, primarily guilt, making it difficult to engage with her surroundings as she desires. She lacks insight into her diagnosis, often saying things like “if I don’t want to be depressed then why am I depressed.” She required extensive socratic questioning to help her gain a little more insight into her diagnosis and feelings of guilt/shame. She denies SI/HI/AVH. She is struggling to make progress toward her goal of identifying triggers or past experiences that contribute to her feelings of guilt and worthlessness, as she requires redirection to provide relevant examples and/or to clarify her comments.

Plan:
Therapist will continue to use CBT informed treatment to help Katie learn coping skills to manage depression symptoms and specifically guilt. For the next week, therapist asks Katie to consider her core beliefs and the source of her core beliefs. She was provided a worksheet to help clarify what core beliefs are and some potential sources. Therapist recommends meeting in one week, Katie will schedule the next session.

Client Signature and Date:
Katie Client, 3/8/23

Clinician Signature and Date:
Olivia Wells, LMFT, 3/8/2023

This document is intended for educational purposes only. Examples are for purposes of illustration only. It is designed to facilitate compliance with payer requirements and applicable law, but please note that the applicable laws and requirements vary from payer to payer and state to state. Please check with your legal counsel or state licensing board for specific requirements.

Progress notes templates you can use today

Using templates makes documentation far faster than starting from scratch each time. Headway offers a library of documentation templates, plus AI-assistance capabilities that make it faster than ever to create compliant notes. But you can also copy and paste the templates below to get started.

SOAP notes template (copy and use today)

Client:

Date:

Session type/length:

Diagnosis/presenting concerns (as applicable):

S: Subjective

  • Client status (mood, symptoms, problems, successes, worries):
  • Client quotes demonstrating status:

O: Objective

  • Clinician observations (affect, behavior, physical appearance, speech style):
  • Therapeutic interventions and modalities used:
  • Measures and assessment scores (if applicable):

A: Assessment

  • Diagnosis:
  • Clinical assessment (change in status, symptom progression)):
  • Progress toward goals and/or obstacles blocking progress:
  • Risk and safety assessment (if relevant):

P: Plan

  • Plan and goals for future treatment, including treatment plan adjustments (if applicable) :
  • Recommended interventions:
  • Coordination/referrals and homework assigned (if any):
  • Next session date/frequency:

DAP notes template (copy and use today)

Client:

Date:

Session type/length:

Diagnosis/presenting concerns (as applicable):

D: Data

  • Client report and direct quotes about status:
  • Clinician observations:
  • Interventions used and assessment scores (if applicable):

A: Assessment

  • Diagnosis:
  • Clinician interpretation of data collected during session:
  • Progress toward goals and/or response to treatment:
  • Risk/safety assessment (if relevant):

P: Plan

  • Plan for future treatment, including recommended interventions or goals:
  • Adjustments to treatment plan (if necessary):
  • Next session date/frequency:

Clinical language to use in progress notes

There should be no “throwaway” language in your progress notes. Every word should be precise and accurate, carefully chosen to capture your client’s true status and convey it clearly to insurers and, if needed, other providers.  

CategoryClinical words for documentation
Mood & emotionsFlat affect, anxious, depressed, irritable, euphoric
BehaviorsAgitated, engaged, withdrawn, cooperative, lethargic, hyperactive
Risk & safetySuicidal ideation, homicidal ideation, self-harm, high-risk, auditory verbal hallucinations
Treatment progressRegressing, plateauing, maintaining, relapsing, achieving, progressing

How to use AI-assisted progress notes

Documentation is undeniably important — but also undeniably time-consuming. Increasingly, providers are streamlining the process by using artificial intelligence tools to help draft progress notes.

These tools work in different ways, but generally use information provided by a clinician (or captured directly during a session, with client consent) to automatically draft a progress note. Some tools are built specifically to generate notes that meet insurers’ standards, but clinicians must still review the finished product to confirm its accuracy and compliance.

Headway providers have access to Scribe, an AI note-taking assistant that:

  • Can turn a brief session summary into a fully compliant note 
  • Can draft a compliant note directly from a session transcript
  • Works with existing documentation templates
  • Can cut documentation time in half

"The quality is incredible,” says LMHC Leah Drizin. “I barely had to do any editing at all.”

Are progress notes just for insurance?

Progress notes are a requirement for billing sessions with insurance, but they also simply provide a written record of the care you delivered. 

Even therapists who operate their practices through self pay should document progress notes. There may be times when thorough mental health care documentation becomes important, such as if your client transitions to a new provider or ends up in a health crisis or legal proceeding. 

“If your patient is in some type of crisis — not even a mental health crisis but something like a car accident — they may end up in a hospital telling their care team, ‘yeah I see a therapist’,” says Turner. “Their care team might need to know what’s been going on in your care, so they can provide consistent care — like not giving medication that might cause issues.”

Along with taking care of billing and ensuring you get paid on time, Headway’s EHR helps streamline your practice. With features like AI-assisted note-taking and built-in documentation templates, Headway’s EHR makes it easier than ever to create progress notes that are both compliant and clinically useful. Consolidating to one system for billing and documentation can also save you valuable time and energy, so you can focus more on what matters most: supporting your clients on their mental health journeys.

How to bill and code progress notes

It’s important to choose the medically appropriate billing code for the correct service delivered, and ensure your documentation supports and substantiates the service.

For talk therapists:

  • CPT code 90834: 45 minutes of psychotherapy, where the total time spent with the patient is 38–52 minutes
  • CPT code 90837: 60 minutes of psychotherapy, where the total time spent with the patient is 53–60 minutes

For psychiatrists and nurse practitioners:

  • CPT code 99204: 45-minute new patient outpatient visit, where the total time spent with the patient is 45–59 minutes
  • CPT code 99205: 60-minute new patient outpatient visit, where the total time spent with the patient is 60–74 minutes

Notes associated with 45-minute sessions should include a connection to the client’s diagnosis, symptoms, and plan, as well as details about how the session impacted their symptoms. 

A 60-minute session note should include all the same details, as well as notes relating to medical necessity of why extra time was needed for more intensive treatment. This doesn’t have to be extensive – it just needs to be directly acknowledged. (You can find examples of medical necessity statements to help you craft your notes.)

It’s important to use the code that most accurately reflects the time you spent with the patient to treat their condition, and ensure that documentation for the session supports the chosen code.

Documentation of relevant aspects of client care, including documentation of medical necessity, should ideally be completed within 24 hours of visit, and no later than 72 hours.

FAQs about progress notes

Still have questions about progress notes? That’s understandable, as it takes a while to get the hang of mental health documentation. Below, answers to some common provider questions.

Does a therapist have to release progress notes?

Progress notes are part of a client’s medical record and may be shared with other providers when relevant to treatment. Clients also have the right to request access to their own progress notes. Therapists are obligated to release them unless there’s an extenuating circumstance, such as credible belief that the client will be harmed by reading their notes. 

What’s the difference between psychotherapy notes and progress notes?

Think of psychotherapy notes as the private version of progress notes. These notes, sometimes also called process notes, contain a therapist’s personal reflections on and analysis of a session. They’re not part of a client’s medical record, which means they generally can’t be accessed by third parties (including the client) without your written permission. 

Are group therapy progress notes different?

Group therapy practitioners often use the same formats used to draft individual progress notes, such as SOAP notes. But group progress notes can be complex. They should focus on the central patient — that is, the person whose insurance is being billed — but also describe interpersonal dynamics and interactions within the group. 

Headway streamlines your documentation process

Headway’s team and tools are here to make everything about working with insurance companies (including compliance) as easy as possible. Along with making billing easier, Headway offers built-in EHR features that simplify administrative tasks like intakes, notes, and treatment plans. Our AI assistant, Scribe, also slashes documentation time, allowing you to turn transcripts or session summaries into full notes in a matter of minutes. Plus, Scribe was built with insurance standards in mind, so you never have to worry about trading compliance for efficiency.

Talk to a practice consultant

This content is for general informational and educational purposes only and does not constitute clinical, legal, financial, or professional advice. All decisions should be made at the discretion of the individual or organization, in consultation with qualified clinical, legal, or other appropriate professionals.

© 2026 Therapymatch, Inc. dba Headway. All rights reserved. No part of this publication may be reproduced without permission.

Compliance and documentation