Effective documentation is critical to client care with psychotherapy notes often being the most common type of clinical documentation mental health professionals will complete in a day. There any many styles of progress notes from which mental health professionals can choose. Whether it’s a SOAP, DAP, or other format, progress notes allow mental health professionals to track client progress, communicate on progress with other professionals, record events during services, and protect themselves in a number of events such as an audit or investigation. If you’re interested in the SOAP note style of notes, check out this guide here.
While the SOAP or PAIP or DAP style of notes provide a structured approach to progress notes, some clinicians prefer a more unstructured, narrative style of notes especially if these clinicians work in a setting that does not rely on insurance.
What are some benefits to using a less structured approach to progress notes? Why not work to create a single standard for progress notes? First, research in health analytics has indicated that as natural language processing has advanced, unstructured clinical notes can allow providers to “say what they want” and can even potentially lead to better patient care. Second, using an unstructured approach allows the clinician to remain flexible in treatment and assessment; it can allow them to adapt the progress note according to the client’s needs instead of adapting the note to a single form in an EHR. Therefore, the clinician would not have to constantly be updating their forms and could spend more time on describing pertinent information in detail. It is also important to remember that structured note styles were created within the context of the medical model. As the medical model continues to move towards standardized forms in EHRs, possibly due to the influence of the growing standards by health insurance models, clinical documentation has been more focused on drop-down checklists and check boxes for symptoms. Counseling and other mental health fields, however, were created within a wellness model. Some researchers have suggested that due to therapy’s, specifically, counseling’s, reliance on the wellness model, a structured approach to progress notes is incompatible with certain therapy styles or approaches.
So now that we’ve reviewed some potential benefits to unstructured progress notes, let’s discuss how to actually write an effective unstructured progress note. I cannot emphasize enough that this is not a one-size-fits-all approach to progress notes. If you are supervised in your current position, ask your supervisor for sample notes to as a model for your own progress notes. You can also ask any insurances your paneled with to provide their guidelines on documentation.
When I worked in a setting that emphasized unstructured progress notes, I used the following as the most general of structures to guide my notes:
- 1 sentence on how client presented for session.
- 1-2 sentences reviewing homework and/or current presenting issues
- 1-2 sentences on interventions
- 1 sentence on client’s response to intervention
- 1 sentence on assessment of progress
- 1 sentence on plan/homework for next session
Here is a sample of an unstructured progress note (*not based on a real client):
Client presented with usual content behavior for session, speech normal. Reviewed homework from last session on list of characteristics for potential romantic partners. Client stated he needed someone who matched his energy. Client reported he had registered on several dating apps since last session to “see what was out there”. Reviewed how dating apps might assist client with therapeutic goal of increasing social connections and finding potential romantic partner. Role-played how client might respond to various dating app scenarios. Client reported he found it helpful to compare healthy and unhealthy communication skills and stated he felt more prepared for these scenarios. Client able to identify healthy communication skills. Client agreed to continue to practice communication skills at next session.
As you might be able to tell, some parts of an unstructured note can be pretty similar to a SOAP, PAIP, or DAP note. Be sure to check out more resources on unstructured progress notes here and here. Baird also Mollen have also written more on unformatted progress notes in their textbook Internship, Practicum, and Field Placement Handbook: A Guide for the Helping Professions.
Want more information documentation? Check out my series Theory to Practice.
Would you use unstructured progress notes in your practice? Comment below!