Progress notes are how therapists document what happens in session — the clinical record that supports continuity of care, meets compliance requirements, and justifies treatment to insurers. They're also one of the most time-consuming parts of the job.
This guide covers what belongs in therapy progress notes, walks through common formats with templates and examples, and offers practical strategies for writing faster without sacrificing quality.
Progress notes document what happened in a therapy session: the client's presentation, interventions used, how the client responded, and next steps. They serve multiple purposes — clinical continuity, legal protection, and insurance documentation.
Under HIPAA, progress notes are part of the medical record and can be shared with other providers, insurers, or (in some cases) the client. This is different from psychotherapy notes, which contain your private process notes — detailed session content, impressions, and hypotheses that receive stronger privacy protections and are kept separate from the medical record.
Because progress notes may be read by others, they should be factual, clinically relevant, and professional. They're not the place for personal reflections or raw clinical speculation.
Most therapists use a structured format to organize their notes. The three most common are SOAP, DAP, and BIRP. Format choice is often driven by agency requirements, insurance expectations, or personal preference — all three are clinically valid.
Subjective, Objective, Assessment, Plan. The most widely recognized format, originally from medical settings but adapted for mental health. Good when you need clear separation between client reports, observations, interpretation, and next steps.
View SOAP guide →Data, Assessment, Plan. Combines subjective and objective into a single Data section, making it more streamlined for therapy contexts where that distinction is less critical.
View DAP guide →Behavior, Intervention, Response, Plan. Emphasizes what the client presented, what you did, and how they responded. Particularly useful for tracking intervention effectiveness.
View BIRP guide →This format-agnostic template captures the essential elements of a therapy progress note. You can adapt it to fit SOAP, DAP, BIRP, or any other structure your practice uses.
Presenting Concerns: [Client's reported symptoms, concerns, and current state.] Interventions Used: [Specific therapeutic techniques, tools, or approaches applied during session.] Client Response: [How the client reacted to interventions, engagement level, insights gained.] Clinical Assessment: [Your interpretation of progress, emerging patterns, treatment effectiveness.] Plan / Next Steps: [Homework, follow-up timing, interventions to continue or introduce.]
Here's a realistic example of a therapy progress note for a session addressing depression. Notice how each section stays focused, interventions are named specifically, and the client's response includes measurable change.
Client reported increased depressive symptoms over the past two weeks, including low motivation, disrupted sleep (waking at 4am, unable to return to sleep), and withdrawal from social activities. Rated mood as 3/10. Client stated: "I feel like I'm just going through the motions." Denied suicidal ideation.
1. Behavioral activation: Collaboratively identified three low-effort activities client previously enjoyed (walking, calling friend, cooking). 2. Cognitive restructuring: Examined evidence for thought "Nothing will help." 3. Psychoeducation on depression-sleep cycle and sleep hygiene basics.
Client engaged actively in behavioral activation planning, identifying walking as most accessible. When examining evidence for "Nothing will help," client acknowledged past episodes where symptoms improved with treatment. Stated: "I guess I do know this doesn't last forever." Mood improved slightly by session end (self-reported 4/10). Client agreed to try one behavioral activation activity before next session.
Client is experiencing a depressive episode with vegetative symptoms (sleep disruption, low motivation) and cognitive distortions (hopelessness). Client demonstrates insight when prompted and shows willingness to engage in behavioral strategies. No safety concerns at this time. Current symptoms warrant increased session frequency.
1. Client to complete one behavioral activation activity (15-minute walk) at least 3x before next session. 2. Client to implement one sleep hygiene change (consistent wake time). 3. Increase session frequency to twice weekly until symptoms stabilize. 4. Continue cognitive restructuring targeting hopelessness. 5. Next session scheduled for [date].
The longer you wait, the more mental energy it takes to reconstruct what happened. Five minutes right after a session often saves fifteen minutes later — and produces more accurate notes.
Not everything that happened needs to go in the note. Ask yourself: would another clinician need this information to continue care? If not, it probably doesn't need to be documented.
'Client appeared tearful' is observable. 'Client was sad' is an interpretation. Observable language keeps your documentation defensible and clinically precise.
Progress notes aren't session transcripts. Capture key themes, interventions, and responses — not every topic that came up or every word exchanged.
When possible, include how the client responded in quantifiable terms. '7/10 anxiety at start, 4/10 after intervention' is more useful than 'anxiety improved.'
'Continue therapy' tells nobody anything. 'Continue weekly CBT focusing on exposure hierarchy for social anxiety' gives the next reader — or future you — something to work with.
Formats like SOAP, DAP, or BIRP reduce decisions. When you're not deciding what to include or how to organize it, you can focus on clinical content instead of structure.
These patterns can reduce the clinical usefulness of your notes or create compliance issues:
Writing novels instead of summaries
More isn't always better. A concise note that captures the essentials is more useful — and more compliant — than a lengthy narrative filled with tangential details.
Including irrelevant details
Personal anecdotes, small talk topics, and details that don't inform treatment clutter the record and can create liability. Stick to what's clinically relevant.
Forgetting measurable outcomes
If you used an intervention, document how the client responded. Without outcome data, you can't track treatment effectiveness or justify continued care.
Vague intervention descriptions
'Provided supportive therapy' tells the next reader nothing about what you actually did. Name specific techniques, tools, or approaches.
Copy-pasting without updating content
Reusing the same note language across sessions makes documentation less useful and can raise compliance red flags. Each note should reflect what actually happened.
AfterSession is an AI therapy note generator built specifically for mental health professionals. Speak or type a brief summary of your session, and receive a structured progress note in seconds — formatted in SOAP, DAP, BIRP, or other formats.
You review and edit before saving, so you stay in control of the clinical content. There are no session recordings stored, and the infrastructure is designed with HIPAA alignment in mind.
Start your free trial and generate your first structured progress note in minutes.
Try AfterSession FreeA realistic therapy progress note example with a reusable template, format comparisons (SOAP, DAP, BIRP), common documentation mistakes, and tips for writing session notes faster.
A realistic SOAP note example from a therapy session, with a reusable template, common documentation mistakes to avoid, and tips for writing notes faster.
A realistic DAP note example from a therapy session, with a reusable template, common documentation mistakes to avoid, and tips for writing notes faster.
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