How to Document Progress Notes

Progress notes can be found in all types of environments. Counselors keep track of inpatient progress in inpatient drug treatment facilities with progress notes, teachers often make progress notes on students, and caregivers keep them on patients and some employers keep track of employees with progress notes. Any situation where an individual's progress needs to be monitored can benefit from progress notes. Writing a progress note isn't difficult once you understand the purpose of progress notes and how to write effectively toward fulfilling that purpose.

Things You'll Need

• Progress Note Form

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Instructions

• 1

  Write progress notes on a form made specifically to include the name of the individual you're keeping notes on. You can make these forms up in a word processor, but there is typically a form available specifically for keeping progress notes. Date each new progress note and define the purpose of the progress note. This information goes at the top of each note form.

• 2

  Begin each progress note with a recap of the individual's previous note. This will give the new progress notes proper context. Don't fully reiterate what was written in previous notes. A brief note about goals that may have been set in previous progress notes is sufficient to build a foundation for your current progress note.

• 3

  Talk with the individual before you begin writing new progress notes. Discuss the progress you feel has been made and ask for the individual's opinion about how he feels regarding his progress. If the notes are for an employee and you previously set production goals, for instance, discuss the previous goals and compare the employee's current production to his production at the time of the previous review.

• 4

  Write the current progress note in relation to the previous progress note, cross referencing the previous note when necessary to illustrate the current progress of an individual. If there were goals to be met, indicate those goals with a cross reference and explain in the current progress note whether the goals were reached and how the individual reached them. If goals were not met, make a note about how the individual plans to meet them before the next progress report.

• 5

  Write progress notes in first or third person, but be sure to support information you include. If you do write something that is based strictly on your opinion, introduce the statement with something like "In my observation," to indicate opinion based on something you've personally noted.

• 6

  Sum up the current progress note with your thoughts regarding an individual's progress and whether or not you feel she is progressing as she should or if she needs more work. If there are additional goals to be met or steps that need to be taken to better the individual's progress, be sure to note those in the final section of the current progress note.