How to Write Progress Notes & Service Plans

Progress notes and service plans (typically referred to as treatment plans) are used in conjunction in various health and mental health environments, including hospitals, inpatient or outpatient drug and alcohol rehabilitation facilities, and residential care facilities. A treatment plan defines the treatment process individual patients will undergo and progress notes are used to track a patient's progress during the course of treatment. Using the two in conjunction allows health institutions to provide a higher level of effective care for their patients.

Instructions

• 1

  Meet with patients several times to determine their background and the type and level of treatment necessary. This is called an assessment. Level of treatment refers to inpatient or outpatient. In many cases, a patient with more severe issues may need intensive inpatient treatment while a patient with less severe issue may be able to attend treatment one or two times a week.

• 2

  Devise a treatment plan tailored to meet the needs of individual patients. In a drug and alcohol rehabilitation setting, patients may need to attend family counseling in addition to meeting with counselors regarding how to cope with living a sober life. In the case of someone who has been involved in an accident, physical therapy and trauma counseling will likely be a part of the treatment plan. A treatment plan should:

  A) Identify the problem
  B) Introduce goals for overcoming the problem
  C) Outline methods of overcoming the problem

• 3

  Begin the progress note with an assessment of your patient's current status. State only facts in a progress note. Give your personal assessment of your patient's beginning state in your treatment notes, which are side notes made to accompany the treatment plan. These notes can be more specific and contain your personal recommendations for a patient, as well as personal observations.

• 4

  Date each progress note. For inpatient treatment facilities, write any activities the patient was able to participate in, how the patient seemed to respond, and any observations. Always use words such as "seemed" or "appeared." This allows you to write about a patient's progress without stating as fact things you can't be certain of.

• 5

  Sign each entry and draw a line from the end of the note to the edge of the paper. This shows the end of your entry and will alert any reader to material written after your entry.