Get Care Notes Template

In the simplest terms, progress notes are brief, written notes in a patient's treatment record, which are produced by a therapist as a means of documenting aspects of his or her patient's treatment. Progress notes may also be used to document important issues or concerns that are related to the patient's treatment.

11 Tips for Writing Professional Progress Notes Always check that you are writing in the relevant person's notes. ... Use a blue or black pen. ... Write legibly. ... Note the date of your entry. ... Sign your entry. ... Avoid blank space between entries. ... Make it clear if notes span more than one page. ... Errors happen.

Do not make assumptions about patients, limiting your thinking and limiting solutions to healthcare goals. Don't provide unnecessary information - Progress notes can be a tedious process and take time, so make sure you only include what is relevant to the patient and their treatment.

Best Practices for Writing Progress Notes Ensure your notes always mention the time and date of entry, the duration of your sessions and your signature. Refer to your previous progress note entries for continuity. Document your notes as soon as possible after each session so you don't forget any important details.

Progress notes record the date, location, duration, and services provided, and include a brief narrative. Documentation should substantiate the duration and frequency of service delivery. The narrative should describe the following elements: Client's symptoms/behaviors.

Progress notes must include both positive as well as negative developments and be written impartially, including any errors made by the carers. Notes must be specific and informative, but also succinct and clear. They must be written in plain English and be easily comprehensible by anyone who reads them.