A progress note template is a fixed set of headings a clinician fills in after each session. Common behavioral health formats are SOAP, DAP, BIRP and GIRP.
This page gives a fill-in template for each format, a sample note for each, and the Medicare rules behind them.
mdhub drafts the note from your session
Your clinician reviews and signs
START FREE TRIAL →What is a progress note?
A progress note is the clinical record of one session. It goes in the client's chart, supports the claim, and tells the next clinician where treatment stands.
It is a different record from psychotherapy notes. HIPAA, 45 CFR 164.501 defines psychotherapy notes as a clinician's notes on what was said in a counseling session. They are kept "separated from the rest of the individual's medical record". The definition excludes session times and "the modalities and frequencies of treatment furnished". It also excludes any summary of the diagnosis, treatment plan, symptoms and progress. Those items belong in the progress note. Our guide to psychotherapy notes covers the difference in detail.
Progress notes and psychotherapy notes compared
| Progress note | Psychotherapy notes | |
|---|---|---|
| Where it lives | In the client's chart | Kept apart from the chart |
| What it holds | Session times, interventions, symptoms, progress, plan | The clinician's private impressions of the conversation |
| Used for billing | Yes, it supports the claim | No |
| Shared with payers | On request | Needs the client's authorization, with narrow exceptions (45 CFR 164.508) |
| Required | After every billed session | Optional |
What must a therapy progress note include?
Medicare LCD L33252 is a local coverage policy for psychotherapy. It says the record "must indicate the medical necessity of each psychotherapy/psychoanalysis session". Its billing article A57520 adds the time and signature rules. Check the LCD for your own Medicare contractor. Medicaid and commercial payers set their own rules, so check each payer's policy too.
| Element | What to write | Source |
|---|---|---|
| Client and date | Full name and date of service on every page | A57520 |
| Session time | Start and stop times, or total minutes, for 90832, 90834 and 90837 | A57520 |
| Symptoms | Symptoms or behaviors severe enough to change baseline functioning | L33252 |
| Interventions | What you did in the session, described specifically | L33252 |
| Client response | Participation, reaction to the session, change or no change in symptoms | L33252 |
| Progress toward goals | Movement on the goals in the treatment plan | L33252 |
| Plan changes | Why the plan changed or therapy was extended | L33252 |
| Diagnosis | The note supports the ICD-10-CM code on the claim | A57520 |
| Signature | Legible signature of the treating clinician | A57520 |
L33252 names two failure points directly. The documentation "must be clear and concise". And "Statements such as "supportive psychotherapy given" are not adequate." A note that names the intervention and the client's response passes. A note that names only the service type does not.
Free progress note template
Copy these headings into your EHR or a document. They work for any format and cover every element in the table above.
Fill-in progress note template
- Client: full name, date of birth, record number
- Date of service: date, start time, stop time, total minutes
- Service: CPT code, location or telehealth, others present
- Diagnosis: ICD-10-CM code(s) addressed today
- Presenting concerns: symptoms and behaviors reported or observed
- Mental status: mood, affect, risk screen
- Interventions: the methods used and what was worked on
- Client response: participation, reaction, change in symptoms
- Progress: movement on each treatment plan goal
- Plan: homework, next session date, any change to the plan and why
- Signature: clinician name, credentials, date signed
Which progress note format should you use?
Pick the format your clinic and your payers expect, and use it for every clinician.
| Format | Sections | The note opens with |
|---|---|---|
| SOAP | Subjective, Objective, Assessment, Plan | What the client reports |
| DAP | Data, Assessment, Plan | Client report and your observations together |
| BIRP | Behavior, Intervention, Response, Plan | The client's presentation |
| GIRP | Goal, Intervention, Response, Plan | The treatment plan goal |
SOAP progress note template
- Subjective: what the client reports, in their words where it helps
- Objective: what you observed, mental status, scores on measures
- Assessment: your clinical reading of today and progress on goals
- Plan: next steps, homework, next session, changes to the plan
Sample SOAP note · fictional client
- S: Client reports two panic attacks this week, both on the subway. Rates anxiety 7 out of 10.
- O: Alert and oriented. Speech fast, affect anxious. GAD-7 score 14, down from 17. Denies suicidal ideation.
- A: Panic disorder, improving. Client used paced breathing once and cut one attack short.
- P: Interoceptive exposure next session. Homework: breathing log daily. Next visit in 1 week.
- Time: 2:00 to 2:53 pm, 53 minutes, 90837. Signed by the treating clinician.
For more SOAP samples by setting, see our SOAP note examples.
DAP progress note template
- Data: what the client said and what you observed, together
- Assessment: your interpretation and progress on goals
- Plan: what happens next and when
Sample DAP note · fictional client
- D: Client discussed conflict with her manager. Tearful when describing the performance review. PHQ-9 score 12.
- A: Depressive symptoms steady. Client named two thinking traps without prompting, which is new.
- P: Continue CBT, thought record before the next work meeting. Next session Thursday.
- Time: 10:00 to 10:45 am, 45 minutes, 90834.
Our guide to DAP notes has more examples.
BIRP progress note template
- Behavior: the client's presentation, symptoms and what they reported
- Intervention: the specific methods you used
- Response: how the client reacted and what changed
- Plan: next steps and changes to treatment
Sample BIRP note · fictional client
- B: Teen client arrived 10 minutes late, withdrawn, said school was "pointless". Denies self-harm.
- I: Motivational interviewing on school attendance. Built a decisional balance sheet together.
- R: Client engaged after 15 minutes and named one reason to attend: seeing friends at lunch.
- P: Parent session next week. Track attendance daily. Next visit in 1 week.
- Time: 4:10 to 4:50 pm, 40 minutes, 90834.
See our guide to BIRP notes for more samples.
GIRP progress note template
- Goal: the treatment plan goal this session worked on
- Intervention: what you did toward that goal
- Response: how the client responded
- Plan: the next step toward the goal
Sample GIRP note · fictional client
- G: Goal 2, reduce drinking to under 3 days a week.
- I: Reviewed drink log, practiced refusal skills by role play for a work dinner.
- R: Client drank on 4 days, down from 6. Role play went well on the second try.
- P: Use the refusal script at Friday's dinner. Review the log next session.
- Time: 11:00 to 11:50 am, 50 minutes, 90834.
Progress notes for psychiatry visits
When a prescriber does therapy in the same visit as medication management, the note covers two services. A57520 says the documentation "should show that they are separately identifiable services". Record psychotherapy start and stop or total time separately. A57520 says "The total time does not include the E/M time." Our pages on 90833 and 90836 show a full example.
Sample psychiatry progress note · fictional client
- Medication management 15 min: sertraline raised to 100 mg after side effect review. Labs reviewed.
- Psychotherapy 30 min, 3:15 to 3:45 pm: CBT for sleep worry, built a wind-down routine.
- Billed 99214 + 90833. Return in 4 weeks.
Progress notes for group therapy
Write a note for each client in the group. Record the group topic, then that client's participation and response. Group psychotherapy is billed as 90853.
Progress notes for family therapy
L33252 sets its own rule for family sessions, with or without the patient present. The record "must indicate the medical necessity of each family psychotherapy session". It also asks for the patient's reaction to the family and the family's reaction to the patient. See 90846 and 90847 for the codes.
Interactive complexity in the progress note
When 90785 is added to a psychotherapy code, A57520 says "the documentation must indicate the amount of time spent in providing interactive complexity services". Name the communication factor too, such as a caregiver whose behavior interfered.
Progress note phrases that fail an audit
Payers reject notes that name the service but not the work. Swap the left column for something like the right one:
| Weak line | Stronger line |
|---|---|
| Supportive psychotherapy given | Validated grief over job loss, then problem-solved two steps for the job search |
| Client doing better | Panic attacks down from 4 to 2 a week; client used breathing twice |
| Discussed coping skills | Taught box breathing and practiced it twice in session |
| Continue plan | Continue weekly CBT; add exposure work next session for Goal 1 |
| Client engaged | Client completed the thought record and named one new thinking trap |
| Session held | Session 2:00 to 2:53 pm, 53 minutes |
How progress notes connect to the treatment plan
Every progress note should point back to a goal in the treatment plan. L33252 expects the plan to carry "measurable and objective treatment goals" and to be updated "generally at least every three months". When the plan changes, the progress note records why.
Our treatment plan template and biopsychosocial assessment template cover the documents that come before the first progress note.
When should you write the progress note?
Medicare's psychotherapy rules set no deadline for the note. Your state board and payer contracts may set one, so check both and apply the strictest to every clinician.
Before the claim goes out, check the minutes match the code. A57520 gives 16 to 37 minutes for 90832, 38 to 52 for 90834 and 53 or more for 90837. It also says "Do not report psychotherapy of less than 16 minutes duration". See 90832, 90834 and 90837 for the time ranges.
Sources
- CMS Medicare Coverage Database, LCD L33252: Psychiatric Diagnostic Evaluation and Psychotherapy Services
- CMS Medicare Coverage Database, Billing and Coding: Psychiatric Diagnostic Evaluation and Psychotherapy Services (A57520)
- 45 CFR 164.501, HIPAA definition of psychotherapy notes
- 45 CFR 164.508, HIPAA authorization rule for psychotherapy notes
Streamline Your Practice
A progress note has to be written after every session, while the details are fresh. mdhub drafts the note from the session in your clinic's own template, for your clinician to review and sign. Start a free trial, or book a demo if you run a clinic with 10 or more clinicians.
Progress note template FAQ
The date and session times, symptoms, interventions and the client's response. Add progress toward treatment plan goals, the plan for next time and the clinician's signature.
The one your payers and clinic already expect. Pick one and use it for every clinician.
A progress note is part of the medical record and supports the claim. Psychotherapy notes are the clinician's private notes, kept apart from the record under HIPAA.
The clinician's private reflections, which belong in psychotherapy notes. Also leave out vague lines such as "supportive psychotherapy given".
Long enough to show the interventions, the response and progress on goals.
For Medicare codes 90832, 90834 and 90837, A57520 requires start and stop times or total time.
Medicare LCD L33252 expects updates generally at least every three months. Each progress note should link the session to a goal in that plan.
AI can draft the note from the session. The clinician reviews, edits and signs it, and is responsible for its content.
