Sample of a Progress Notes

Progress notes are a detailed record of a patient’s progress during treatment. They are typically written by healthcare professionals, such as doctors, nurses, or therapists, and are used to document changes in a patient’s condition, response to treatment, and any other relevant information.

A sample progress note might look like this:

Patient Name: John Doe

Date: December 7, 2022

Subjective:

• Patient reports feeling more energetic and less depressed since starting antidepressant medication
• Patient states that they have been sleeping better and have had more motivation to engage in activities
• No reported side effects from medication

Objective:

• Vital signs within normal limits
• Patient appears well-groomed and oriented to person, place, and time
• Patient is able to complete simple math calculations

Assessment:

• Depression symptoms appear to be improving
• No significant side effects from medication
• Continue current treatment plan and monitor for further improvement

Plan:

• Continue current antidepressant medication
• Follow up with patient in 2 weeks to assess progress
• Refer to therapy for additional support

Overall, progress notes provide a detailed and ongoing record of a patient’s treatment and can be an important tool for monitoring their progress and ensuring the best possible care.

Sample of a Progress Notes -2

Client Name: Jane Doe Date: 10/1/20

Session Objective: To improve Jane’s ability to identify and express her emotions in a healthy manner.

Session Details:

• Started the session with a brief check-in and review of previous session goals.
• Jane reported feeling overwhelmed and anxious due to recent changes at work.
• We discussed the importance of identifying and expressing emotions in a healthy manner.
• Jane was able to identify and label her feelings as anxious and overwhelmed.
• We practiced deep breathing and grounding techniques to help Jane manage her anxiety in the moment.
• We also discussed strategies for dealing with overwhelming emotions, such as reaching out to supportive friends and family, journaling, and engaging in relaxation activities.
• Jane was able to identify a few people she could reach out to for support and agreed to try journaling and relaxation activities on her own.
• Ended the session with a review of goals and homework assignments for next session.

Assessment:

Jane demonstrated progress in her ability to identify and express her emotions in a healthy manner. She was able to label her feelings and utilize coping skills to manage her anxiety. Continued practice and support will be important for her to continue to improve in this area.