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312 The Routine Progress Note

This document provides a format for a routine progress note in 3 sections: 1) Identifying information including client name, date, duration and frequency of sessions, diagnoses, and GAF score. 2) Tracking of target symptoms and changes, treatment provided, and treatment planned. Standard codes are suggested to efficiently record this information. 3) Signature and identifying information of the person completing the note. Footnotes provide additional context and suggestions for standardized coding approaches.

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edzuckerman
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141 views2 pages

312 The Routine Progress Note

This document provides a format for a routine progress note in 3 sections: 1) Identifying information including client name, date, duration and frequency of sessions, diagnoses, and GAF score. 2) Tracking of target symptoms and changes, treatment provided, and treatment planned. Standard codes are suggested to efficiently record this information. 3) Signature and identifying information of the person completing the note. Footnotes provide additional context and suggestions for standardized coding approaches.

Uploaded by

edzuckerman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as RTF, PDF, TXT or read online on Scribd
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312

Format for a routine progress note

(On your letterhead or other identification of the professional creating the note)
Case Progress Note
Page _____

Name of client ____________________________________ Date ____/_____/20___


Start _____ Ending _____ times. Duration 90 7560

50 45 30

15 minutes

Intended schedule: Biweekly

Weekly

12 weeks PRN

Diagnosis (DSM-IV/ICD) _________________________________ Code # _________


Diagnosis (DSM-IV/ICD) _________________________________ Code # _________
GAF score today __________ Other measures*_________________________________
Target Symptoms
Change since ____ date
**Change ________________________________________________________ ____
__________________________________________________________________ ____
__________________________________________________________________ ____
__________________________________________________________________ ____
__________________________________________________________________ ____
Treatment provided**______________________________________________________
______________________________________________________________________
Treatment planned*** _____________________________________________________
_______________________________________________________________________
Current/Changed medications****

See _________________________

Prognosis: q Guarded q Improvement q Recovery q Fluctuating q ____________


Notes ** _______________________________________________________________

_______________________________________________________________________
_______________________________________________________________________
_______________________________________________________________________
Person completing this form: _____________________ ___________________ ______
Signature/Initials

Printed

Title

Notes
* Depending on the case you might use the Y-BOCS for obsessive/compulsions, the Beck Depression or
Anxiety Inventories, or dozens of other. All are improvements over the anchorless GAF.
** If you wish to enter any datum on every note, assigning a code makes for less recording time and space.
Examine your current notes to decide what might be coded.
For example, you might use this code for degree of Change
<< = Much worse
<
= Worse
=
= No change
>
= Improved
>>
= Greatly improved

Similarly, if you need to record the modalities of treatment you might assign MM to medication monitoring, F to
family therapy, C for conjoint, I for individual, and G for group. You could add a sub-code such as sm for stress
management, resoc for resocialization/social skills, etc. If you need to record who was present you might code F for
father, M for mother, Sn for son Ss for sister, etc. Or you might prefer to use the SOAP format and enter those letters
-Subjective, Objective, Assessment, and Plan. For more on using SOAP or SOAPIER notes in psychotherapy see
Zuckerman, 2003.
*** You might enter homework, or changes in the plan and record the treatment plan separately and use a code here.
**** Or you might keep track of medications on a separate sheet or indicate who is responsible for medication for this
client.

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