Progress Note Template Types
Choose the right template format for your healthcare specialty
General Medical Progress Notes
Standard format for tracking patient progress in medical settings
Key Features:
- Chief complaint and history updates
- Physical examination findings
- Assessment and plan modifications
- Response to treatment
- Next appointment planning
Therapy Progress Notes
Specialized templates for mental health and therapy sessions
Key Features:
- Session goals and objectives
- Therapeutic interventions used
- Client response and engagement
- Homework completion
- Treatment plan updates
Rehabilitation Progress Notes
Templates for physical therapy and rehabilitation tracking
Key Features:
- Functional status assessment
- Exercise tolerance and performance
- Pain levels and mobility
- Goal achievement tracking
- Discharge planning
Progress Note Examples
Real-world templates for different healthcare specialties
Primary Care Follow-up
SUBJECTIVE:
Patient reports [symptoms/concerns]. Compliance with medications: [compliance status]. Any new symptoms: [new symptoms or 'none'].
OBJECTIVE:
Vital signs: BP [value], HR [value], Weight [value]. Physical exam: [relevant findings]. Lab results: [if applicable].
ASSESSMENT:
Condition: [improved/stable/worsened]. Current medications: [effective/needs adjustment]. Overall progress: [assessment].
PLAN:
Continue [current treatments]. Modify [any changes]. Next visit: [timeframe]. Patient education: [topics discussed].
Mental Health Therapy
SUBJECTIVE:
Client reports mood as [rating/description]. Sleep: [quality/hours]. Anxiety/depression levels: [scale rating]. Medication compliance: [status].
OBJECTIVE:
Appearance: [grooming/dress]. Mood/affect: [observed]. Speech: [rate/volume]. Thought process: [organized/disorganized]. Insight: [level].
ASSESSMENT:
Progress toward goals: [specific progress]. Therapeutic alliance: [quality]. Symptom severity: [improved/same/worse]. Treatment response: [effectiveness].
PLAN:
Continue [interventions]. Homework: [assignments]. Next session focus: [topics]. Frequency: [schedule]. Referrals: [if needed].
Physical Therapy
SUBJECTIVE:
Pain level: [0-10 scale]. Functional limitations: [specific activities]. Sleep quality: [impact]. Medication use: [frequency].
OBJECTIVE:
Range of motion: [measurements]. Strength: [grades]. Balance: [assessment]. Gait: [observations]. Functional tests: [results].
ASSESSMENT:
Impairments: [current status]. Functional progress: [percentage/description]. Goal achievement: [met/partially met/not met]. Prognosis: [outlook].
PLAN:
Continue [exercises/modalities]. Progress [specific activities]. Home program: [modifications]. Next visit: [focus]. Discharge planning: [timeline].
Progress Tracking Best Practices
Guidelines for effective patient progress documentation
Documentation Standards
- Use consistent formatting across all notes
- Include specific, measurable progress indicators
- Document both improvements and setbacks
- Reference previous treatment goals and outcomes
- Use objective language and avoid subjective interpretations
Progress Tracking
- Establish baseline measurements at initial visit
- Use standardized assessment tools when appropriate
- Track functional outcomes, not just symptoms
- Document patient's perspective on progress
- Include family/caregiver observations when relevant
Treatment Planning
- Adjust goals based on current progress
- Set realistic, achievable short-term objectives
- Consider patient preferences and lifestyle factors
- Plan for potential barriers to progress
- Include discharge criteria and timeline
Progress Measurement Tools
Standardized tools to track and document patient progress
| Assessment Tool | Use Case | Frequency | Progress Indicator |
|---|---|---|---|
| PHQ-9 | Depression screening and monitoring | Every 2-4 weeks | Decreasing score over time |
| GAD-7 | Anxiety assessment | Every 2-4 weeks | Reduced anxiety symptoms |
| Pain Scale (0-10) | Pain level tracking | Each visit | Decreasing pain ratings |
| Functional Status | Activities of daily living | Weekly | Improved independence |
| Goal Attainment | Treatment goal tracking | Each session | Percentage of goals met |
Progress Note Documentation Tips
Essential guidelines for effective progress documentation
Effective Practices
- Use specific, measurable language
- Compare to previous assessments
- Document both progress and setbacks
- Include patient's own words when relevant
- Update treatment plans based on progress
Common Mistakes
- ✗Using vague terms like "doing well"
- ✗Copying previous notes without updates
- ✗Focusing only on problems, not progress
- ✗Failing to document patient perspective
- ✗Not updating goals based on progress