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Progress Note Form Template

Create Accurate and Efficient Progress Notes

Keeping track of patient progress can be overwhelming, especially when dealing with multiple cases. This progress note form template is designed to help healthcare professionals effectively record patient information, ensuring better tracking of treatments and outcomes. With clear sections for patient history, current status, and treatment plans, you can streamline your documentation, enhance communication with your team, and comply with legal standards. Plus, it's WCAG-aligned for accessibility, making it a reliable choice for diverse healthcare environments. Explore this live template to simplify your note-taking process.

Use this Template (FREE) Live Preview
Client full name
Date of birth
Client ID / MRN
Phone number
Email address
Session date
Session type
Initial evaluation
Follow-up
Crisis visit
Group session
Family session
Telehealth
In-person
Duration (minutes)
Location
Clinic
Client home
Telehealth
School
Community setting
Other
Please Specify:
If Other location, specify
If Other present, specify
Who was present
Client
Parent/guardian
Partner/spouse
Family member
Case manager
Interpreter
Other
Please Specify:
Chief concern / primary focus of session
Mood
Euthymic
Depressed/low
Anxious
Irritable
Elevated
Labile
Not assessed
Other
Please Specify:
Affect
Congruent
Restricted
Flat
Labile
Incongruent
Not assessed
Thought content
Logical
Ruminations
Obsessions
Delusions
Preoccupations
Within normal limits
Not assessed
Perception
No abnormalities noted
Auditory hallucinations
Visual hallucinations
Other perceptual disturbances
Not assessed
Mental status notes
Insight and judgment
Good
Fair
Limited
Poor
Not assessed
Current suicidal ideation
Yes
No
Current homicidal ideation
Yes
No
Self-harm behavior since last session
Yes
No
Substance use since last session
Yes
No
Overall risk level
Low
Moderate
High
Not assessed
Risk and safety notes
Safety plan updated or created today
Yes
No
Interventions provided
Please Specify:
If Other intervention, specify
Client participation and engagement
Minimal
Moderate
Active
Not applicable
Response to interventions
No change reported
Some improvement
Significant improvement
Worsening
Not applicable
Interventions and response notes
Overall progress toward treatment goals
Poor
Fair
Good
Very good
Excellent
Diagnoses (ICD-10/DSM-5)
Clinical formulation and assessment
Measures or screening tools used today
PHQ-9
GAD-7
PCL-5
AUDIT-C
DAST-10
C-SSRS
None
Treatment plan updated today
Yes
No
Homework or assignments
Referrals made today
Psychiatry
Primary care
Group therapy
Specialist
Community resources
Crisis services
None
Other
Please Specify:
If Other referral, specify
Next appointment date
Follow-up notes
Recommended frequency
Weekly
Biweekly
Monthly
As needed
To be determined
Consent to telehealth on file
Yes
No
Release of information on file
Yes
No
Attendance status
Completed
No-show
Late cancellation
Rescheduled
Partial session
Billing code and units
Supervisor name
Supervisor required
Yes
No
Provider full name
Provider credentials
Provider signature (type full name)
Date signed
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Paper art illustration depicting a progress note form template for a digital tool on note-taking and form creation.

When to use this form

Use this template whenever you need a quick, consistent record of a follow-up visit, therapy session, or case management check-in. It helps physicians, therapists, and nurses capture what changed since last contact, what you observed, and what you will do next. For medical teams, the Patient progress notes form works well for daily rounding and continuity across shifts. Behavioral health teams can adapt the Outpatient psychiatric progress note form to track symptoms, safety, and medication changes. If you coordinate services across programs, the Client progress notes form keeps goals, interventions, and outcomes aligned. The result: clear documentation that supports handoffs, billing, and audits without slowing you down.

Must Ask Progress Note Questions

  1. What is the patient's main concern or goal since the last visit?

    This focuses the note on the most important change and sets a measurable target. It also keeps care patient-centered and makes progress easy to judge at the next appointment.

  2. What objective findings did you observe today (vitals, MSE, behaviors, labs)?

    Objective data reduces bias and supports clinical decisions and medical necessity. Clear observations also help other providers trust and use your documentation.

  3. What interventions or treatments did you provide, and how did the patient respond?

    Linking actions to responses shows clinical reasoning and effectiveness. It guides plan adjustments and supports coding and reimbursement.

  4. Are there any risks or safety concerns, and what actions did you take?

    Documenting suicide risk, withdrawal, falls, or side effects triggers timely safeguards. It protects the patient and provides legal clarity on your decisions.

  5. What is the plan, who is responsible, and when is the follow-up?

    A concrete plan with owners and dates drives accountability and continuity. If you supervise trainees, align tasks with the Clinical supervision form for oversight.

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