Therapy Progress Notes: Templates, Examples, and What to Include
By Kristen McClure, MSW, LCSW | TherapistWorksheet.com
Progress notes are one of the most time-consuming parts of a therapist’s week — and one of the least taught. Most clinicians develop their note-writing style through trial and error, borrowing from supervisors or colleagues, or defaulting to whatever the EHR template requires.
This guide gives you a practical framework for writing notes that are clinically accurate, legally defensible, and efficient.
What Progress Notes Are Actually For
Progress notes serve four functions simultaneously:
- Clinical continuity — your memory of what happened, what you noticed, what you’re thinking
- Legal protection — documentation that you provided appropriate standard of care
- Insurance justification — demonstrating medical necessity for continued treatment
- Communication — with other providers, supervisors, or future treaters
The most common mistake: writing notes only for the insurance auditor and losing the clinical utility entirely. A good note does all four.
The SOAP Note Format for Therapy
S — Subjective
What the client reported. Their words, their experience, their account of the week. Use attribution language: “Client reports,” “Client states,” “Client describes.”
Example: “Client reports increased anxiety over the past week following a conflict with her supervisor. She describes difficulty sleeping and ruminative thoughts focused on work performance. She states her mood has been ‘a 4 out of 10.'”
O — Objective
What you directly observed. Affect, behavior, appearance, engagement in session. Do not put client reports here — only what you witnessed.
Example: “Client presented as well-groomed. Affect was anxious and constricted. Mood as stated above. Thought process was organized. Client was engaged and responsive throughout session.”
A — Assessment
Your clinical impression — not a restatement of the diagnosis. Be specific about today’s session.
Example: “Client continues to present with symptoms consistent with GAD. Today’s session revealed a pattern of catastrophizing related to perceived professional inadequacy. Safety assessment: no current suicidal ideation, plan, or intent. Client remains appropriate for outpatient level of care.”
P — Plan
What happens next. Be specific about interventions used and planned.
Example: “Utilized CBT techniques to identify and challenge cognitive distortions related to work performance. Client agreed to complete thought record before next session. Continue weekly individual therapy. Next session: [date].”
The DAP Format (Simpler Alternative)
D — Data: Everything that happened — combines Subjective and Objective. What the client reported plus what you observed.
A — Assessment: Your clinical impression.
P — Plan: What’s next.
DAP is faster to write and works well for straightforward sessions. SOAP provides more structure when clinical complexity warrants it.
What Every Progress Note Needs
- Date of service and session length
- Diagnosis (DSM-5 code with specifiers)
- Client presentation, mood, and affect
- Topics addressed in session
- Interventions used — be specific (“Socratic questioning to examine core belief,” not just “CBT”)
- Client response to interventions
- Safety assessment result
- Progress toward treatment goals
- Plan for next session
- Your signature and credentials
Common Progress Note Mistakes
Too vague to be useful
Bad: “Client discussed family issues. Good session. Will continue.”
Better: “Client explored ongoing conflict with mother around perceived criticism. Identified core belief ‘I am never good enough.’ Practiced cognitive defusion. Client reported moderate insight.”
No safety documentation
Every note should document that you assessed for safety. “No current suicidal or homicidal ideation reported” takes five seconds and protects you significantly.
Writing client reports as facts
“Client was abused as a child” — this presents second-hand information as established fact. Write: “Client reports a history of childhood abuse.”
Copy-paste notes
The format can be consistent. The content must reflect this client’s specific session. Copy-paste notes are flagged in audits and are a significant liability risk.
How Long Should a Progress Note Be?
A well-structured SOAP note for a standard 50-minute session: 150–300 words. If your notes consistently take more than 15 minutes per session, your template needs to work harder.
Frequently Asked Questions
How soon after session should I write progress notes?
Same day is the gold standard. Most licensing boards and insurance payers require notes within 24–72 hours. Check your payer contracts and state requirements.
Can I use the same template for every client?
The format can be consistent. The content must reflect this specific client’s session. Copy-paste notes are flagged in audits and are a real liability risk.
What if a client asks to see their notes?
Under HIPAA, clients generally have the right to access their records. Write every note as if the client might read it — because they might.
What goes in a progress note vs. a psychotherapy note?
Psychotherapy notes (process notes) are separately stored and have additional HIPAA protections. Progress notes are part of the medical record and may be shared with payers. Keep the distinction clear.
Kristen McClure, MSW, LCSW is a licensed therapist who creates practical clinical tools to help therapists navigate the hardest moments in their work.