Ethical considerations for progress notes: What to leave in, what to leave out

Back in graduate school, you likely learned all about best practices for writing progress notes. And if you’ve worked in numerous treatment settings since then, you’ve likely been trained on many other approaches to writing an effective, compliant progress note. 

But this abundance of information may simply leave you feeling confused. When you sit down to document your progress notes, you might wonder “What’s really required? What’s too much? What happens if I write too little?”

These unknowns can make it difficult to write efficient, quality notes that also meet the requirements of commercial payers. But with some practice and a clear strategy in mind, you can learn to write a sound progress note in no more than 10 minutes. It all boils down to creating a simplified notetaking workflow and knowing exactly what to leave in and what to leave out.

How to write quality mental health progress notes

There are a few essential elements of a progress note that should always be included.

Documentation of medical necessity 

The most critical element of a progress note is the inclusion of clinical information that demonstrates “medical necessity” for the service. In basic terms, this means the documentation shows that the client has clear treatment needs that require intervention from a licensed therapist. In order to bill your clients’ insurance for your services, commercial payers will look for the following in your progress note to reflect medical necessity: 

• Covered diagnosis: A diagnosis listed in the DSM-5TR. In a commercial payer world, covered diagnoses are typically limited to F codes. 

• Symptoms: Include the symptoms the client reports that are in alignment with the stated diagnosis. 
• Functional impairment(s): How the client’s mental health symptoms impact their ability to function at work, school, in relationships, etc.
• Therapeutic interventions used in the session: These should be few in number, specific and relevant to the client’s goal for treatment, and based in a clinical strategy that is only accessible via a licensed therapist. For example, instead of noting “Therapist taught client a coping skill” say “Therapist taught client a grounding exercise utilizing the five senses to support client in management of social anxiety.”
• Client response to interventions and progress towards goals: Specify how and if the chosen interventions are helping the client meet their treatment goals and objectives.
• Plan for next steps in upcoming therapy sessions: So much of treatment happens outside of the session. The plan section should reflect what the client will do between this session and the next to make progress towards their treatment goals. 

Documentation of risk 

Another “must have” for effective progress notes is clear documentation of risk (and changes to risk level) when clinically indicated. This applies to clients who present with risk factors or who have previously been assessed to be at moderate or high risk of harm to self, harm to others, or suicidality. 

Noting the status of risk ensures that your documentation reflects that you provided thorough, responsive care. While the specific details of this documentation will vary depending on the client’s situation, here are some recommendations on what to include in progress notes when risk is present: 

• List of current or relevant risk factors such as substance use, poor social support system, feelings of hopelessness, recent job loss, the anniversary of a major loss, etc.
• Completion of a Columbia Suicide Severity Rating Scale (C-SSRS) and notation of results.
• Completion of a safety plan, or documentation that the safety plan was reviewed if it was created previously. Notation of the client’s access to 24/7 crisis support or other supportive resources for use outside of scheduled therapy with the provider.

Use person-first language

As you document the session, keep in mind that how you write about your client’s experience matters. Remember that clients can request to review these notes, and their full record set, at any time. 

The use of language is critical to ensuring a recovery-oriented and person-centered approach. It’s important that people are seen first as people and not seen as their mental health condition. For example, instead of noting that your client:

• “Is a cutter” note that they “have a history of non-suicidal self-injurious behavior, specifically cutting”
• “Is a borderline” note that they are “a person diagnosed with borderline personality disorder”
• “Is homeless” note that they are “experiencing homelessness”
• “Is an addict” note that they “are living with a substance use disorder”

What should be left out of progress notes?

Now that you have a clearer understanding of what to include in your progress notes, you might be wondering what to leave out. Many new therapists try to include every detail of their sessions in their notes, worried that they might miss important information.

But documenting highly detailed descriptions of what the therapist said, what the client said, and what was discussed can unintentionally result in the progress note reading as a transcript of the session, instead of a treatment summary. 

This can risk turning documentation into an unnecessarily time-consuming process for the therapist, and can also risk compromising client privacy by including too much detail in the record set, which is discoverable. Simply put, instead of offering a play-by-play of everything that occurred in a session, solid progress notes should offer a strategic summary. 

As you think about what to leave in and what to leave out of your progress notes, ask yourself the following two questions:

• If I only had 30 seconds to summarize this session for a supervisor, what would I say? Focus on why the client needs treatment (remember to focus on specific symptoms and functional impairments) and what occurred in the session to address their concerns. Anything else is likely best left out.
• What does my client’s insurer need to know to justify covering therapy? For example, you should document that your client’s “increased isolation (a primary symptom of their major depressive disorder) has resulted in strained relationships with their partner and increased conflict in the home.” But the client’s insurer doesn’t need to know the granular details of a specific fight that happened this week, etc.

Process notes vs. progress notes, what’s the difference?

Let’s say you’ve written a sound progress note that meets all the requirements of your treatment setting and your professional and ethical standards. You know that this note will be entered into the formal record set in the EHR where they can be accessed by the payer, requested by the client at any time, and can also be subpoenaed by a court. So you’ve included what’s minimally necessary to protect the client’s privacy. Nicely done!

But as a therapist, you know that sometimes important details will surface in sessions that have no place in a progress note. And in order to create effective treatment plans and develop rapport with your client, these details matter. 

So how do you keep track of the information that might be important to you as a therapist but isn’t appropriate for formal entry into the record set? Enter “process notes”, also called psychotherapy notes. These are often handwritten notes that are secured and managed by the therapist and not entered into the client’s chart. They can help you remember important client details, log sensitive information, and ensure continuity between sessions.

How Rula is easing the administrative burden for therapists

From billing and scheduling to managing records and notes, therapists have a lot on their plate. 

At Rula, we support our therapist network by offering comprehensive training and tools for quality clinical documentation to help your practice thrive. This includes videos, help center articles, and even one-on-one consultation with Rula’s Clinical Quality Coaches for feedback and support on your documentation. Plus, our online community is the antidote to the isolation that so many private practice therapists feel. 

To learn more about how Rula can support you in building a virtual private practice, check out our website.