4+ Sample Mental Health Progress Note

What Is a Mental Health Progress Note?

A mental health progress note is a recurring note that licensed behavioral health professionals (e.g., psychologists, counselors, etc.) use to monitor and assess the progress of a patient. It is a brief but standardized form that is generally used in therapy or counseling sessions.

According to the Anxiety and Depression Association of America, Generalized Anxiety Disorder or GAD affects around 3.1% of the population, or around 6.8 million people in the United States. Major Depressive Disorder or MDD affects 16.1 million Americans, aged 18 and older, in a given year. In both scenarios, GAD and MDD are more likely to affect women or are more prevalent in women than in men.    

Tips for Protecting Mental Health

In today’s dramatically fast-paced society, it is becoming more important than ever to protect one’s mental health. Especially in times of uncertainty and fear such as a global pandemic, taking care of one’s overall well-being cannot be emphasized enough. What steps can people take then to help keep the depression and anxiety at bay? The examples below are just simple but powerful ways to safeguard your mental and emotional well-being in difficult times.       

Practice Mindfulness: Awareness is more than just knowing what’s going on externally or what’s around you. Mindfulness has everything to do with what goes on internally. When thoughts are running through your mind, the natural tendency is to chase it or even fight it- especially if we feel it is a negative one. It is important to remember that we do not have to chase or believe every thought that pops into our head. Mindfulness as a technique involves acknowledging your thoughts and emotions as they arrive then gradually letting them go, and not allowing them to take control. So instead of judging the fleeting thought (or emotion) harshly, mindfulness trains us to acknowledge and treat it with more compassion and patience. Keep a Gratitude Journal: Gratitude is a key ingredient for a purposeful and satisfying life. When things get overwhelmingly difficult, it helps to take a step back and acknowledge what you have. By keeping a gratitude list or journal, you are also practicing mindfulness because you are activating your self-awareness. Make it a habit to note everything you are grateful for, from the most seemingly mundane and ordinary to the one thing you value most in your life. Take Care of Your Physical Well-being: Enough studies have shown that physical health is crucially linked to mental health. That is to say that if you take care of your physical health, you are also taking care of your mental and emotional well-being too. So apparently, there is some truth when people recommend working out or engaging in a little sweat session whenever you are feeling down. The chemicals released when your body is moving and exercising can result in a positive change in mood. Regular exercise can help ease the tension you feel in your body and give you an outlet to better cope with the distress and anxiety you may be feeling. Reach Out To Other People: People are not meant to do life alone. It is a big misconception when people believe that self-reliance is a trait to be venerated. Yes, self-reliance and self-sufficiency may be helpful to some extent, but human beings are social creatures at the very core. So in order to safeguard your mental health, connection and community are vital. The modern condition today is widespread loneliness and social isolation. Those two eat at the inherent need for humans to seek and establish connection. Therefore, it is important to always seek help when it’s needed. Reaching out to people you trust and love can serve as a lifeline in times of crisis and confusion. For those struggling with clinical mental health problems like depression, accessing professional help is imperative in addition to having a reliable support network.

How to Create a Mental Health Progress Note

Mental health progress notes often follow a standard code. One technique used by therapists and other health professionals is the SOAP approach. SOAP stands for subjective, objective, assessment, and plan. These provide the necessary structure or guide in creating a sound mental health progress note. There are several templates above that can serve as useful references for you to customize your own progress note. Feel free to browse through them and at the same time, keep in mind the following steps:  

Step 1: List Down Patient Information

A mental health progress note always begins with a summary of basic information about the patient. Indicate the patient’s full name, gender, patient number, date and time of the session, any medications he or she may be on, the type of service or session (e.g., individual therapy, group counseling), contact information, and other relevant details. Most mental health facilities and professionals use a standardized format for progress notes and these may vary in form. Common forms include a questionnaire or a checklist type of form.     

Step 2: Record All Observations 

Therapists, psychologists, and counselors need to be observant in order to create a solid and sound progress note. Mental health professionals are specifically trained to observe a patient in a number of ways. If the SOAP method were to be applied, then both subjective and objective behavior characteristics must be noted down. This includes noting the patient’s mood and appearance. Did the patient seem agitated during the session? Was the patient seemingly withdrawn, indifferent, or distracted over the course of the session? Or maybe he or she was open and engaged in the conversation. Also, observations should not be limited to just the note taker’s assumptions. Physical and outward characteristics can be documented in the progress note as well. Did the patient look disheveled or tired? Does he or she lack sleep? All observations, both obvious and subtle, ought to be included in your progress note.      

Step 3: Do an Assessment 

After gathering enough observations, the mental health professional will proceed to the assessment phase. He or she will try to make sense of the observations and apply accepted theories to evaluate and help the patient. An overall assessment of the type of treatment or the appropriate intervention may be listed down and discussed. Sound judgment that is fair and impartial is a must when it comes to the psychological assessment of the patient. This section also explores the goals and other reasons that are tied to the patient’s history and treatment.   

Step 4: Establish a Follow-up Plan 

Lastly, a mental health progress note is not complete without a follow-through plan. The very nature of a progress note is that it is recurring and meant to systematically track any development. So if a patient attends therapy sessions on a regular basis, monitoring each session is the only way to maximize a solution. By comparing the past to the present conditions, a much better and more holistic picture is presented of the patient’s mental health.     

FAQs

How do you write a mental health progress note?

To write a mental health progress note, it is generally best to do it using a standard approach such as the SOAP method. With a SOAP approach, your progress note should contain subjective and objective observations, an informed assessment, and an action plan. Another strategy is the DAP method. Similar to SOAP, a DAP note must consist of reliable data, an assessment, and a plan.

What is a mental health progress note?

A mental health progress note is a medical note used by mental health professionals to monitor and evaluate a patient’s emotional and cognitive condition.

How do you write a good progress note?

According to an article by Sun Wave Health, to write better therapy progress notes, there are five steps to take into consideration. First, it is important for your writing to be clear and concise. Second, be professional at all costs, even in your language. Third, write for everyone so try to avoid overly technical words and jargon. The fourth tip is to use standardized approaches like the SOAP method. Lastly, make sure to focus on the progress of your patient and adjust as necessary.

Psychotherapy and behavioral health may seem like intimidating disciplines or fields of study, but at the core of it all is the simple desire to understand the mental health and emotional conditions in human beings. A simple mental health progress note is a basic but effective tool that can help achieve this desire. Download a sample template above to start making your own mental health progress note now!