What a therapy progress note is
A progress note is the clinical record of a single therapy session. It documents what was addressed, what you did, how the client responded and what comes next. It is part of the client's medical record and is what payers review to confirm a service was provided and was medically necessary.
Progress notes are different from psychotherapy notes (sometimes called process notes). Psychotherapy notes are your private impressions kept separate from the record and have extra legal protection. Progress notes are the official record, so they should be factual, concise and free of speculation.
SOAP, DAP and BIRP are the three most common ways to structure a progress note. They contain the same essentials and differ in how they organize them, which is why this generator lets you choose.
Choosing a progress note format
- SOAP: medical or integrated care settings, or whenever you record measures and need self-report separate from observation.
- DAP: individual talk therapy where a single narrative Data section reads more naturally.
- BIRP: agency and managed care settings that want each intervention linked to the client's response.
- Your payer, agency or EHR requires one. Then use that one, consistently.
What every progress note needs
Whatever the format, reviewers look for the same elements.
Presentation and symptoms
Current symptoms, mood and functioning, in the client's words and your observations.
Tip: Connect symptoms to the diagnosis being treated. That is the core of medical necessity.
Interventions
The evidence-based techniques you used this session, named specifically.
Tip: One or two well-described interventions beat a list of five vague ones.
Response and progress
How the client responded and how they are progressing toward treatment plan goals.
Tip: Note lack of progress honestly too. It justifies changes to the plan.
Risk and safety
Any screening done and its result, and safety planning if indicated.
Tip: If you screened and the result was negative, document that. Absence of a note reads as absence of a screen.
Plan
Next session focus, homework, referrals and frequency.
Tip: Keep it concrete enough for a covering clinician to follow.
Worked example
Fictional case: an adult client in outpatient therapy for depression, session 9, documented in BIRP. No identifying details.
Session details entered
- Client report
- Mood "a bit better", back to walking 3x a week, still isolating from friends.
- Observations
- Brighter affect than last session, PHQ-9 = 11 (was 15), denies SI.
- Interventions
- Reviewed activity log, problem-solved barriers to texting a friend.
- Response
- Identified one friend to contact, agreed to send one text by the weekend.
Resulting note
Behavior:
Client described mood as "a bit better" and reported walking three times this week, while continuing to avoid contact with friends. Affect was brighter than at the previous session. PHQ-9 score of 11, down from 15. Client denied suicidal ideation.
Intervention:
Clinician reviewed the behavioral activation log with client and used structured problem solving to address barriers to social contact.
Response:
Client recognized the link between activity and mood, identified one friend to contact, and agreed to a specific, small step toward reconnecting.
Plan:
1. Client to send one text to the identified friend before the weekend. 2. Continue walking three times weekly. 3. Readminister PHQ-9 in two weeks. 4. Continue weekly sessions.
Common progress note mistakes
- Copying the previous note forward with small edits, which auditors look for.
- Writing process-note content (your private reactions) into the official record.
- No link between the session and the treatment plan goals.
- Signing notes days later, when details have faded. Many payers set timeliness rules.
Frequently asked questions
Which format should I choose?
If your agency or payer specifies one, use it. Otherwise SOAP suits medical settings, DAP suits talk therapy, and BIRP suits settings that want interventions tied to responses. The note format picker on our tools page can help you decide.
What is the difference between a progress note and a psychotherapy note?
Progress notes are the official clinical record of a session and are shared with payers when needed. Psychotherapy notes are a clinician's separate private notes about the session and are kept apart from the record.
How detailed should a therapy progress note be?
Detailed enough to show what you did, why, how the client responded and what is next, and no more. Most routine notes are a few short paragraphs.
Is this tool free?
Yes, for one note per day without an account. The limit resets 24 hours after your last note.
Can I enter identifying information?
No. This is a public tool for de-identified information only. Leave out names, dates, locations and contact details.