Progress Note Templates
Free, standardized progress note templates for medical, therapy and rehabilitation settings — so every visit ties back to the treatment goals and shows how the patient is doing over time.
Pick your format
Progress note template types
Choose the right template for your 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
Copy or download
Progress note templates
Ready-to-use templates for three common settings. Copy the one you need into your EHR, or download all three as a PDF.
Primary care follow-up
PRIMARY CARE FOLLOW-UP PROGRESS NOTE Follow-up Date: [Date] Interval since last visit: [Time period] 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
MENTAL HEALTH THERAPY PROGRESS NOTE Session Date: [Date] Session #[number] of [total planned] 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
PHYSICAL THERAPY PROGRESS NOTE Treatment Date: [Date] Visit #[number], [weeks] post-injury/surgery 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].
Best practices
Progress tracking that shows the trend
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 the initial visit
- Use standardized assessment tools when appropriate
- Track functional outcomes, not just symptoms
- Document the 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
Measure it
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 |
Documentation tips
Writing progress notes that hold up
Effective practices
- Use specific, measurable language
- Compare to previous assessments
- Document both progress and setbacks
- Include the 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 the patient's perspective
- Not updating goals based on progress
Progress notes that write themselves.
ReasonNotes listens to the visit or session and drafts the progress note in your format — ready to review about a minute after you finish. HIPAA compliant, with a BAA on every plan.
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