Top Tips for Mental Health Progress Notes

Documentation is an art—and it’s one that often comes with its challenges and uncertainties for mental health professionals. Recently, I had the privilege of sitting down with four exceptional colleagues and fellow documentation experts to discuss progress notes. Dr. Ajita Robinson, Barbara Griswold, Beth Rontal, and Beth Irias (host of Light Up the Couch) joined me for a dynamic conversation on writing progress notes.

The podcast episode, The Ideal Progress Note: Myths, Methods, and Best Practices, provided an opportunity to share our tips, explore different opinions, and reflect on what the “ideal” progress note really looks like. Spoiler alert—we all agreed there’s no such thing as perfect, but there are plenty of ways to make progress notes meaningful, efficient, and reflective of your work as a clinician.

Here’s what I learned from these inspiring women, where our opinions aligned, and where my own perspective adds a slightly different take.

The Biggest Takeaway? Capture YOU in the Room

One of the most common themes throughout our discussion was the importance of capturing the therapist’s presence in every progress note. Progress notes are not just about what the client said or did—they should reflect your active role in facilitating progress.

But here’s the challenge many clinicians face: While therapists put a lot of thought and effort into their interventions in-session, those efforts don’t always show up clearly in their notes. It’s not that you aren’t doing great work—you are! However, the nuances of conveying your actions and decisions in writing can get lost during the “translation” into documentation.

My Take

Your interventions—both structured ones and organic, in-the-moment decisions—deserve to be acknowledged in your progress notes. From guiding a client through a breathing exercise to challenging a cognitive distortion, these moments matter. They provide essential documentation of the therapeutic process and highlight your role in achieving client outcomes.

Action Tip: Try creating a list of interventions you use regularly. Templates and cheat sheets can act as starting points, but reviewing your own notes may reveal patterns in your approach. Then, customize your template with language that feels natural and accurately reflects your sessions.

Myth-Busting “Checkbox” Notes

A major pitfall we all agreed on was the reliance on “checkbox-style” notes where therapists simply list modalities—like CBT or mindfulness—without actually explaining what was done. Blanket terms like these don’t say much and can fall short if your notes are reviewed by an auditor, supervisor, or even the client.

Progress notes should be specific enough to clearly illustrate the session. For example, rather than stating “applied CBT,” you might document that you challenged a client’s black-and-white thinking or assisted them in identifying alternative perspectives. Details like these add richness and meaning to your notes while staying concise.

My Take

While I completely agree that progress notes deserve descriptive language, I often see therapists get stuck in perfectionism here. You don’t need to reinvent the wheel for every note. It’s perfectly fine to reuse language or repeat interventions across notes when that reflects your work.

Action Tip: Start with a narrative format for interventions. Use active verbs like “assessed,” “assisted,” “guided,” or “challenged” to describe your role in the session. This simple shift can help notes flow more naturally.

The Debate Over Language

Another topic we discussed was the balance between casual and professional language in notes. Some professionals prefer formal, clinical language, while others value readability and accessibility.

Personally, I lean toward keeping notes clear and easy to read. Overloading progress notes with jargon not only hinders communication but can make them feel impersonal to clients. At their core, progress notes are a reflection of the therapeutic relationship and should reflect humanity while remaining professional.

Where I Agree 

All five of us emphasized that progress notes should explicitly demonstrate what the therapist contributed to the session. This doesn’t mean you need to sound “smarter” or more clinical; it simply means being clear about your role and ensuring actions are thoughtful and intentional.

Action Tip: If you find yourself using casual phrasing, don’t panic! Focus on documenting what’s meaningful and unique about the session instead of trying to meet an imagined language “standard.”

Progress Notes Beyond Fear

A theme I noticed—and wanted to address—is the fear often associated with progress notes. Whether it’s anxiety about audits or worry over insurance requirements, fear can creep into documentation practices. While being cautious is okay, fear shouldn’t be your primary motivator for writing notes.

Instead, think of progress notes as an extension of client care. Writing notes not only completes the session but also connects sessions—providing context and continuity to your therapeutic work.

Keys to Fearless Documentation: 

• Systemize Your Notes: Create a repeatable structure. Templates tailored to your practice and approach can significantly reduce stress.
• Shift Your Mindset: Rather than writing “defensively” for insurance or audits, focus on documenting progress and outcomes for your client.
• Focus on Intentionality: Build habits in how you structure and write notes so it starts to feel natural over time.

Lessons That Stuck With Me

This conversation reminded me why I’m so passionate about helping clinicians simplify their documentation. The insights I shared here only scratch the surface of the rich discussion we had on the podcast.

Every therapist has a slightly different way of approaching documentation based on their style, training, and clients. Yet, the most important thing remains consistent across the board—progress notes are a reflection of the unique work you do as a therapist.

Whether you’re writing SOAP notes, DAP notes, or using another structure, the goal doesn’t change. Show your involvement. Show the client’s story, progress, and outcomes. And above all, remember that documentation is an act of care.

Want More Tips?

If you found these tips helpful, check out my free resources below!

• Get 23 FREE Therapy Interventions: Download my free handout to start documenting interventions more confidently.
• Watch the Podcast Episode: Listen to The Ideal Progress Note for even more professional insights. Get 1 CEU credit here! 

Happy documenting!

-Maelisa